^«p^ 


rs^i^i^ 


.u»AS;|^§rcE|, 


B035 


U\36 


W(^640' 


f63AA 


Suf 


ci\ca\ 


Aag 


RECAP 


trl'hi;!;-:;:!: 


^^:::::;i:v 


•:•'.<;->>■ 


|:^ 


S^SSi?*^-- 


':•>.: 


■■  ■'-  ■  'S'^iii^Sii%vl'is?Vis.-i->i»liL:i  vC?  L'L-^\A  • '  •>il.s.•v<»^;<•^<^X^ 


..1^  ^^<JfKOiO<^^  I. 


vp^>'-'7;"t<%' 


T^3535 


3t 


(Efllutttbta  lmtiFr0ttg 
in  t\^t  (Ettg  0f  N^m  f  ark 


iAtUvtnn  Htbrarg 


wm 


\wr- 


.  /t/ 


> 


SURGICAL  DIAGNOSIS 


BY 


EDWARD  MARTIN,  M.D. 

PROFESSOR    OF    CLINICAL    SURGERY    IN   THE    UNIVERSITY    OF    PENNSYLVANIA 


IFllustrateC)  wttb  445  Bngravings  auD  18  plates 
in  Colors  an&  fnionocbrome 


LEA   &  FEBIGER 

PHILADELPHIA    AND    NEW    YORK 
1909 


Entered  according  to  Act  of  Congress,  in  the  year  1909,  by 

LEA  &   FEBIGER, 

in  the  OflBce  of  the  Librarian  of  Congress.     All  rights  reserved. 


\'j- 


C  U 

^  - 


TO 


J.  WILLIAM  WHITE,  M.D.,  Ph.D.,  LL.D.  (EDm.) 

JOHN    RHEA    BARTON     PROFESSOR    OF     SURGERY    IN   THE    UNIVERSITY    OF    PENNSYLVANIA 


IN    RECOGNITION    OF    HIS    SKILL    AS  .A    SURGEON    AND    HIS    ABILITY 
AND   DEVOTION   AS   A  TEACHER 


THIS   BOOK   IS   DEDICATED 


AUTHOR 


PREFACE. 


The  simplicity  and  safety  of  surgical  intervention  are,  as  a  rule, 
proportionate  to  timeliness  in  diagnosis.  This,  in  turn,  is  usually 
dependent  upon  the  judgment  of  the  general  practitioner,  who  is,  as 
a  rule,  the  first  to  see  the  patient  and  should,  therefore,  be  qualified 
to  determine  at  the  earliest  moment  when  surgical  treatment  is  required. 
The  practitioner  cannot  be  expected,  however,  to  acquire  such  a  knowl- 
edge of  the  probabilities  deducible  from  general  symptoms  and  of  the 
variations  from  type  as  is  necessary  to  establish  the  final  diagnosis.  This 
can  be  gained  only  by  a  conscious  or  subconscious  grouping  of  the  clini- 
cal features  of  many  similar  cases. 

The  proof  of  the  advantage  of  early  diagnosis  is  afforded  by  the 
lessened  mortality  which  is  found  to  result  from  such  diagnosis  in  every 
department  of  modern  operative  surgery.  This  is  in  part  due  to  more 
perfected  technique  and  more  rational  after  treatment,  but  mainly  to 
the  simplicity  of  earlier  operation.  To  this  element  is  also  due,  almost 
entirely,  the  larger  percentage  of  radical  cures. 

Partly  from  custom,  but  mainly  because  of  examination  requirements., 
it  is  the  habit  of  teaching  institutions  to  impress  upon  the  minds  of  their 
students  the  symptom-complex  of  the  completely  developed  disease. 
Such  clear  mental  pictures  are  highly  desirable  from  many  points  of 
view,  but  since  action  is  often  deferred  until  the  picture  is  complete, 
they  may  work  to  the  detriment  of  the  patient.  It  too  often  happens 
that  when  the  disease  is  so  fully  developed  that  the  diagnosis  can  be 
made  beyond  doubt,  the  time  for  surgical  intervention  is  past.  If,  for 
instance,  a  cancer  of  the  breast  is  not  recognized  as  possibly  or  probably 
such  until  the  dense  induration,  skin  adhesion,  nodular  lymphatic 
glands,  and  cachexia  prove  its  nature,  the  only  possible  result  accruing 
to  the  patient  is  the  knowledge  that  she  will  have  but  little  time  to  live 
and  that  she  will  suffer  much.  There  are  many  affections,  the  neoplasms 
constituting  the  most  conspicuous  examples  among  these,  in  which  an 
assured  diagnosis  other  than  by  operative  means  is  impossible  at  the 
time  it  is  likely  to  be  serviceable.  It  seems  reasonable  to  hope  that 
death  or  crippling  or  disfiguring  deformity  from  surface  or  orificial 
malignant  neoplasm  may  become  even  more  rare  than  are  now  those 
monstrous  growths  which  illustrate  the  text-books  and  frequent  the 
clinics.  This  end  will  have  been  attained  in  part  when  it  becomes 
generally  recognized  that  the  diagnosis  of  malignancy  should  be  formu- 
lated by  wide  removal  and  microscopic  examination  of  any  persistent 
outgrowth,  infiltration,  or  ulceration  which  is  not  certainly  benign.     The 


vi  PREFACE 

gross  deformity  of  Pott's  disease,  the  crippling  ankylosis  of  coxalgia, 
the  life-long  pain  and  disability  following  bone  and  joint  traumata  too 
often  represent  sequelae  which  could  have  been  averted  but  for  a  too 
faithful  adherence  to  the  rule  of  formulating  the  diagnosis  and  directing 
the  treatment  only  upon  the  basis  of  a  complete  symptomatology. 

It  is,  therefore,  in  the  interest  of  early  diagnosis  in  its  relation  to 
helpful  and  curative  surgery  that  this  book  is  written.  Consequently, 
stress  is  laid  mainly  upon  symptoms  of  major  and  deciding  moment; 
or,  when  such  are  absent,  upon  the  operative  and  laboratory  means  by 
which  a  conjecture  may  be  transformed  into  a  probability  or  a  certainty. 

In  the  section  devoted  to  Laboratory  Diagnosis,  Dr.  Warfield  T. 
Longcope  has  presented,  with  a  moderation  highly  creditable,  a  state- 
ment of  the  help  that  may  be  given  the  surgeon  by  those  who  work 
with  the  microscope,  culture  media,  and  test-tube. 

Dr.  Henry  K.  Pancoast  has  shown  in  his  chapter  on  the  X-rays  in 
Surgical  Diagnosis  both  the  value  and  the  limitations  of  a  method  which, 
because  of  its  efficiency,  is  now  as  essential  to  the  surgeon  in  his  exami- 
nation of  patients  as  is  the  anesthetic  in  his  operations  upon  them. 
Dr.  Pancoast's  outline  drawings  of  negatives  in  his  possession  constitute 
the  most  complete  series  of  x-ra,j  fracture  pictures  yet  published. 

In  the  chapter  devoted  to  Gynecological  Diagnosis,  Dr.  Brooke  M. 
Anspach  has  admirably  described  in  detail  the  methods  found  most 
serviceable  in  his  hospital  and  private  practice. 

Dr.  Theodore  H.  Weisenburg  has  based  his  chapter  on  the  Diagnosis 
of  Nervous  Affections  upon  a  wide  experience  with  those  diseases  of  the 
nervous  system  in  which  surgical  intervention  must  be  considered. 

Such  merit  and  accuracy  of  statement  as  may  be  found  in  the  section 
devoted  to  the  Eye  are  due  to  the  criticisms  and  suggestions  of  Dr. 
George  E.  de  Schweinitz. 

E.  M. 

Philadelphia,  1909. 


CONTENTS. 


CHAPTER  I. 
Laboratory  Diagnosis 17 

CHAPTER  IT. 
The  Application  of  the  X-rays  in  Surgical  Diagnosis 37 

CHAPTER  III. 
Inflammation 68 

CHAPTER  IV. 
Complications  and  Sequels  op  Trauma 78 

CHAPTER  V. 
Tumors 82 

CHAPTER  VI. 
The  Skin 84 

CHAPTER  VII. 
The  Bloodvessels 96 

CHAPTER  VIII. 
The  Lymph  Vessels  and  Glands 101 

CHAPTER  IX. 
The  Muscles,  Tendons,  and  Burs^e 107 

CHAPTER  X. 
The  Bones  and  Joints 118 

CHAPTER  XI. 

Diseases  op  the  Nervous  System 140 


viii  CONTENTS 

CHAPTER  XII. 
The  Head,  Face,  and  Neck 223 

CHAPTER  XIII. 
The  Spinal  Column 332 


CHAPTER  XIV. 
The  Upper  Extremity 345 


CHAPTER  XV. 
The  Thorax 451 

CHAPTER  XVI. 
The  Abdomen 477 

CHAPTER  XVII. 
The  Lower  Extremity 556 

CHAPTER  XVIIT. 
The  Genito-urinary  Organs 640 

CHAPTER  XIX. 
Gynecological  Diagnosis 693 


Index 739 


SURGICAL  DIAGNOSIS. 


CHAPTER    I. 

LABORATORY  DIAGNOSIS. 
By  WARFIELD  T.  LONGCOPE,  M.D. 

EXAMINATION  OF  THE  BLOOD. 

At  the  present  time  our  knowledge  of  the  chemistry  of  the  blood  and 
blood  serum  is  not  sufficiently  advanced  to  offer  much  aid  in  the  practical 
study  of  a  patient.  In  certain  conditions  a  spectroscopic  examination 
of  the  blood  may  reveal  the  presence  of  an  abnormal  substance,  such  as 
carbon  monoxide  hemoglobin.  Until  more  knowledge  has  been  accu- 
mulated, too,  regarding  the  variations  in  the  reactions  of  the  blood, 
estimations  of  the  alkalinity  cannot  prove  of  much  value. 

On  the  other  hand,  a  determination  of  the  coagulation  time  of  the  blood 
may  be  of  great  importance.  To  a  surgeon  who  is  about  to  operate,  a 
knowledge  of  the  fact  that  the  formation  of  a  blood  clot  is  delayed  twenty 
or  thirty  minutes  may  obviate  an  unpleasant  experience.  To  estimate 
the  coagulation  time  of  the  blood,  Wright's  tubes  may  be  used,  but  the 
new  instrument  devised  by  Boggs  is  much  simpler  in  application  and 
probably  more  accurate.  The  most  common  condition  in  which  the 
time  of  coagulation  shows  the  greatest  diminution  is  jaundice,  especially 
when  incident  to  chronic  pancreatitis;  in  severe  cases  the  blood  may 
remain  fluid  after  withdrawal  for  fifteen  to  twenty-five  minutes.  It  must 
be  remembered  that  in  hemophilia,  a  disease  which  offers  great  dangers 
to  the  surgeon,  the  coagulation  time  of  the  blood  may  not  be  decreased. 

The  estimation  of  the  hemoglobin,  a  procedure  which  may  be  done 
with  the  greatest  ease,  will  decide  quickly  whether  or  not  the  patient  has 
an  anemia,  and  combined  with  an  enumeration  of  the  red  blood  corpuscles 
may  give  much  information.  In  many  of  the  acute  infections,  in  chronic 
suppurative  conditions,  in  cachexias  due  to  malignant  growths,  in  cirrhosis 
of  the  liver,  and  in  Bright's  disease,  there  is  always  more  or  less  secondary 
anemia,  with  a  greater  loss  proportionately  in  the  amount  of  hemoglobin 
than  in  the  numbers  of  red  blood  cells.  Immediately  after  an  acute 
hemorrhage  the  blood  picture  may  be  very  nearly  normal,  for  the 
absorption  of  fluid  from  the  blood  is  so  great  that  the  loss  of  the 
formed  elements  is  not  obvious.  Later,  a  loss  in  hemoglobin,  relative 
to  the  size  of  the  hemorrhage,  and  a  less  marked  reduction  in  the  red  cells 


18  LABORATORY  DIAGNOSIS 

become  evident.  Wlien  small  but  frequent  hemorrhages  take  place  the 
diminution  of  hemoglobin  and  loss  of  red  blood  corpuscles  progress 
slowly,  but  finally  the  blood  picture  may  reach  that  of  an  extreme  grade 
of  anemia.  The  anemia  in  the  above  condition  is  due  either  to  an 
actual  loss  of  red  blood  cells  through  hemorrhage  or  to  a  destruction 
of  red  blood  cells  in  the  circulation  through  the  action  of  some  toxic  or 
poisonous  substances.  Smears  from  the  blood  show  that  the  red  blood 
cells  are  small  and  pale  (Plate  I).  There  may  be  some  irregularity  in 
size  and  shape  of  the  cells,  but  this  is  not  usually  marked.  Except 
in  the  severest  secondary  anemias,  nucleated  red  blood  cells  are  not 
numerous,  and  almost  always  when  present  they  are  of  the  normo- 
blastic type. 

Progressive  pernicious  anemia  is  to  be  sharply  differentiated  from  the 
great  group  of  secondary  anemias.  The  exact  cause  of  pernicious 
anemia  is  not  known,  but  its  mode  of  origin  is  different  from  that  of  the 
secondary  anemias,  inasmuch  as  the  anemia  is  not  alone  due  to  a 
destruction  of  red  cells  in  the  circulating  blood,  but  to  an  injury  of  the 
vital  tissue  which  forms  the  red  blood  cells  for  the  body — the  bone  mar- 
row. The  red  corpuscles  in  this  disease  fall  relatively  lower  than  the 
hemoglobin,  so  that  the  hemoglobin  index  is  above  1.  The  leukocytes  are 
decreased.  Microscopically  the  red  blood  corpuscles  show  great  irregu- 
larity in  size  and  shape  (Plate  II).  Many  of  them  are  much  larger 
than  normal.  Nucleated  red  blood  corpuscles  are  found,  sometimes 
in  great  numbers,  and  the  megaloblasts  are  often  more  plentiful  than 
the  normoblasts.  The  blood  picture  serves  to  distinguish  cases  of 
pernicious  anemia  from  severe  secondary  anemia,  which  may  accompany 
hidden  carcinoma  of  the  internal  organs,  or  follow  repeated  losses  of 
small  amounts  of  blood. 

Great  importance  has  been  attached,  within  recent  years,  to  estima- 
tions of  the  white  cells  or  leukocytes  of  the  blood.  In  dealing  with  this 
subject  it  must  be  remembered  that  the  leukocytes  play  a  very  definite 
part  in  the  economy  of  the  body,  and,  so  far  as  we  know  at  present,  are 
principally  concerned  in  protecting  the  organism  against  injurious  agents, 
among  which  are  certain  pathogenic  bacteria. 

The  knowledge  that  the  numbers  of  these  cells  in  the  circulating  blood 
may  vary  greatly  from  normal,  in  many  acute  diseases,  and  even  in  some 
chronic  afiFections,  has  been  of  much  assistance  in  the  diagnosis  of  certain 
conditions.  Under  normal  circumstances  the  variation  in  the  mmabers 
of  the  leukocytes  is  not  very  great,  and  we  can  consider  7000  to  10,000 
leukocytes  per  c.mm.  within  the  normal  limits.  When  the  leukocytes 
are  increased,  perhaps  to  15,000,  to  20,000,  or  to  50,000  per  c.mm.,  we 
speak  of  the  condition  as  leukocytosis;  and  when  they  fall  below  the 
normal  limit,  the  condition  is  known  as  leukopenia. 

Several  varieties  of  leukocytes  go  to  make  up  the  total  number  of  these 
white  cells,  and  of  all  the  leukocytes,  the  polymorphonuclear  neutrophilic 
leukocytes  are  the  most  numerous.  They  form  70  per  cent,  to  72  per  cent, 
of  the  cells.  Next  in  numbers  are  the  small  lymphocytes,  which  make 
up  22  per  cent,  to  25  per  cent,  of  the  cells.     The  large  lymphocytes  and 


/^>/ 


f 


/" 


# 


y^>i7 


/^^^/ 


Fcff.vm. 


f    9 


i       J         k      i        m 


i>nAi>VM  BY  J.N Z  CMAii 


PLATE   1 


BLOOD. 

(Ehrlifli   triple  stain.) 
(Prepared  by  Dr.   I.   P.   Lrov.) 

Fig.  I.     TYPES    OF    LEUCOCYTES. 

a.  Polymorphonuclear  Neutrophile.  b.  Polymorphonuelear  Eosinophile.  c.  Myelocyte 
(Neutrophilic),  d.  Sosinophilie  Myelocyte,  e.  Large  Lymphocyte  (large  Mononuclear). 
/.  Small  Lymphoeyte  (small  Mononuclear). 

Fig.  II.     NORMAL   BLOOD. 
Field  contains  one  neutrophile.     Reds  are  normal. 

Fig.  III.    AN.EMIA,  POST-OPERATIVE  (secondary). 

The  reds  are  fewer  than  normal,  and  are  defleient  in  hsemoglobin  and  some-what 
irregular  in  form.  One  normoblast  is  seen  in  the  field,  and  two  neutrophiles  and  one 
small  lymphoeyte,  showing  a  marked  post-hsemorrhagie  anaemia,  with  leueocytosis. 

Fig.  IV.     LEUCOCYTOSIS,  INFLAMMATORY. 

The  reds  are  normal.  A  marked  leueocytosis  is  shown,  with  five  neutrophiles  and 
one  small  lymphoeyte.  This  illustration  may  also  serve  the  purpose  of  showing  ths 
leueocytosis  of  malignant  tumor. 

Fig.  V.     TRICHINOSIS. 
A  marked  leueocytosis  is  shown,  consisting  of  an  eosinophilia. 

Fig.  VI.     LYMPHATIC  LEUKEMIA. 

Slight  anaemia.  A  large  relative  and  absolute  increase  of  the  lymphoejtes  (chiefly 
the  small  lymphocytes)  is  shown. 

Fig.  VII.     SPLENO-MYELOGENOUS    LEUKEMIA. 

The  reds  show  a  secondary  anemia.  Two  normoblasts  are  shown.  The  leueocytosis 
is  massive.  Twenty  leucocytes  are  shown,  consisting  of  nine  neutrophiles,  seven  myelo- 
eytes,  two  small  lymphocytes,  one  eosinophile  (polymorphonuclear)  and  one  eosinophiUe 
myelocyte.  Note  the  polymorphous  condition  of  the  leucocytes,  i.e.,  their  variations 
from  the  typical  in  size  and  form.. 

Fig.  VIII.     VARIETIES   OF    RED    CORPUSCLES. 

a.  Normal  Red  Corpuscle  (normocyte).  6.  c.  Anasmie  Red  Corpuscles,  d-g.  Poikiloeytes. 
h.  Microeyte.  i.  Megalocyte.  j-n.  Nucleated  Red  Corpuscles.  J,  k.  Normoblasts,  i.  Micro- 
blast,    m,  n.  Megaloblasts. 


PLATE  II 

FIG.    1 


Pernicious  Ansemia. 

The  field  shows  marked  anisocytosis  and  poikilocytosis:  -If,  young  megaloblast  (early  generation); 
M-  M'^  M*,  later  generations  of  the  megaloblast  series;  S  S  S,"  stippled"  red  cells;  R,  ring  body  (nuclear 
remnant  ?);  L,  lymphocyte. 

FIG.    2 


Pernicious  Anaemia.     (Actual  Field.) 

Field  showing  less  poikilocytosis  than  Fig.  1:  M^,  young  megaloblast;  M-,  megaloblast  of  later 
generation;  T  T  T,  etc.,  transitional  erythroblasts,  not  typical  either  of  the  megaloblastic  or  of  the 
normoblastic  series;  S,  "stippled"  erythrocyte;  P,  polynuclear  neutrophile;  L,  large  lymphocyte. 


EXAMINATION  OF  THE  BLOOD  19 

transitional  cells  form  3  percent,  to  5  percent.,  the  eosinophilic  leukocytes 
2  per  cent,  to  4  per  cent.,  and  the  basophiles  0.5  per  cent. 

In  the  commoner  forms  of  leukocytosis  these  cells  do  not  increase 
proportionately.  One  form  predominates  above  all  others,  both  relatively 
and  in  actual  numbers,  and  this  form  is  the  polymorphonuclear  leukocyte. 
The  reason  for  this  is  not  far  to  seek.  If  one  injects  a  culture  of  some 
bacterium,  such  as  Staphylococcus  aureus,  into  the  peritoneal  cavity  of 
a  rabbit,  the  polymorphonuclear  leukocytes  pour  from  the  bloodvessels 
of  the  mesentery  into  the  peritoneal  cavity  to  protect  the  body  against  the 
toxic  action  of  the  bacteria.  So  many  leukocytes  leave  the  blood  stream 
that  for  a  short  time  the  numbers  of  white  cells  in  the  peripheral  circula- 
tion are  actually  diminished.  But  the  body  soon  feels  the  need  of  more 
leukocytes.  Great  quantities  of  these  cells  are  required  in  the  perito- 
neum, and  they  must  reach  the  peritoneum  from  their  point  of  origin 
through  the  blood  stream.  New  leukocytes,  therefore,  are  rapidly 
formed  in  the  bone  marrow  and  poured  in  great  numbers  into  the  cir- 
culation, whence  they  find  their  way  to  the  peritoneum.  This  generous 
supply  of  cells  circulating  through  the  bloodvessels  produces  the  leuko- 
cytosis. 

If,  now,  a  culture  is  chosen  which  is  extremely  virulent,  and  if  this  is 
inoculated  into  the  animal  in  great  quantity,  the  rabbit  may  die  very  soon 
and  without  the  appearance  of  a  leukocytosis.  The  explanation  of  this 
fact  is  found  in  the  severity  of  the  intoxication.  The  body  cells,  including 
those  which  form  the  leukocytes,  are  so  badly  injured  by  the  bacterial 
toxins  that  leukocytes  cannot  be  formed  readily;  not  only  is  it  impossible 
for  the  body  to  furnish  leukocytes  in  excess  of  what  is  required,  but  it 
cannot  even  produce  sufficient  numbers  to  combat  the  infection. 

It  may  readily  be  seen  that  leukocytoses  cannot  be  considered  by  rule 
of  thumb.  When  great  quantities  of  leukocytes  are  required  for  some 
purpose  in  any  part  of  the  body,  the  body  cells  do  their  best  to  produce 
leukocytes  in  excess  of  what  is  actually  needed,  and  the  number  of  these 
cells  increase  in  the  blood. 

Though  it  is  impossible  to  draw  definite  conclusions  from  the  grade 
of  leukocytosis,  still  certain  general  principles  may  be  followed  in  those 
infections  where  a  leukocytosis  usually  occurs.  If  the  patient  is  not 
very  sick  and  the  leukocytes  are  only  slightly  increased,  we  may  assume 
that  the  infection  is  mild  and  great  numbers  of  leukocytes  are  not 
required  for  protection.  If  the  patient  is  very  ill  and  the  leukocytes 
are  high,  the  body  is  probably  reacting  well  against  the  infection,  but 
if  the  patient  is  very  ill  and  the  leukocytes  remain  low,  the  reaction  of 
the  body  is  poor  and  the  ultimate  outlook  is  grave. 

A  leukocytosis  may  be  physiological  or  pathological.  Physiological 
leukocytoses  occur  after  heavy  meals,  when  the  white  cells  may  increase 
30  per  cent,  to  40  per  cent.,  and  after  excessive  exercise  and  cold  baths. 
During  pregnancy  the  leukocytes  increase  50  per  cent,  to  80  per  cent., 
while  in  the  newborn  the  leukocytes  may  be  three  to  four  times  their 
normal  number  in  the  adult. 

Pathological  leukocytoses  occur  in  a  great  variety  of  conditions,  and 


20  LABORATORY  DIAGNOSIS 

certain  diseases  are  almost  always  accompanied  by  a  leukocytosis. 
Among  these  conditions  may  be  mentioned  pneumonia,  rheumatic  fever, 
epidemic  meningitis,  septicemia,  erysipelas,  scarlet  fever,  and  tetanus.  In 
practically  all  forms  of  pyogenic  infections  and  purulent  inflammations 
there  is  a  leukocytosis  of  varying  degree,  and  sometimes  a  leukocytosis 
which  is  quite  high.  In  localized  acute  inflammations  'a  leukocytosis  is 
the  rule,  and  it  is  sometimes  surprising  to  find  what  a  marked  leukocy- 
tosis accompanies  a  comparatively  mild  infection.  A  small  boil  may 
give  rise  to  a  leukocytosis  of  20,000  to  25,000  cells  per  c.mm.  Purulent 
inflammations  of  the  pleura,  the  pericardium,  and  the  peritoneum  are 
usually  accompanied  by  a  great  increase  in  the  leukocytes.  In  empyema 
it  is  not  uncommon  to  find  a  leukocytosis  of  20,000  to  50,000  cells  per 
c.mm.  The  same  is  true  of  acute  purulent  inflammations  of  the  gall- 
bladder and  such  internal  organs  as  the  liver,  kidneys,  and  brain. 

In  appendicitis  the  leukocytes  may  vary  considerably,  depending  upon 
the  stage  of  the  disease.  With  acute  catarrhal  conditions  the  leukocytes, 
if  increased  at  all,  are  very  slightly  elevated;  in  the  acute  suppurative 
stages  there  may  be  a  moderate  leukocytosis  (15,000  to  20,000  leuko- 
cytes per  c.mm.),  or  as  the  process  continues  a  very  high  grade  of  leuko- 
cytosis (30,000  to  40,000  leukocytes  per  c.mm.)  may  develop.  As  is 
true  in  all  infections,  the  desperate  fulminating  cases  may  show  but  a 
slight  rise  in  the  leukocytes.  When  the  process  becomes  chronic  the 
leukocytes  may  be  normal,  and  even  though  there  is  a  localized  abscess, 
provided  it  is  walled  off,  the  leukocytes  may  be  scarcely  above  the  normal 
limits.  This,  too,  is  true  of  all  chronic  localized  inflammations.  During 
the  active  stage  of  the  infection,  new  leukocytes  are  constantly  required 
at  the  seat  of  trouble  and  are  constantly  kept  high  in  the  circulating  blood; 
but  in  an  old  walled-off  abscess  no  leukocytes  are  required  of  the  body, 
and  there  is,  therefore,  no  increase  of  the  cells  in  the  blood. 

Though  the  presence  of  a  leukocytosis  may  aid  in  the  diagnosis  of 
certain  conditions,  the  discovery  of  a  leukopenia  may  be  equally  helpful 
in  clearing  the  diagnosis.  Just  as  certain  diseases  are  characterized  by 
an  increase  in  the  leukocytes  others  may  be  recognized  by  a  decrease. 
This  is  particularly  true  of  typhoid  fever,  and  the  knowledge  of  this  fact 
may  serve  to  differentiate  this  disease  from  certain  acute  infections 
which  it  may  so  closely  resemble.  Another  very  important  fact  which 
must  be  borne  in  mind  when  one  is  dealing  with  typhoid  fever  is  that 
secondary  acute  inflammations,  such  as  pneumonia,  subcutaneous  ab- 
scesses, osteomyelitis,  cholecystitis,  and  peritonitis,  complicating  typhoid, 
may  give  rise  to  only  a  slight  leukocytosis,  which  is  in  no  way  comparable 
to  the  leukocytosis  occurring  in  such  acute  infections  alone.  Wliereas, 
the  leukocytes  in  croupous  pneumonia  usually  average  15,000  to  30,000 
cells  per  c.mm.,  and  may  be  much  higher,  in  pneumonia  complicating 
typhoid  fever  the  leukocytes  may  number  only  8000  to  12,000.  If  one 
takes  into  account  the  usual  leukopenia  of  typhoid  fever  (3000  to  6000 
leukocytes  per  c.mm.),  this  represents  an  increase  in  the  leukocytes  of  the 
blood,  but  is  insigniflcant  as  compared  with  the  leukocytosis  seen  in 
croupous  pneumonia  itself. 


EXAMINATION  OF  THE  BLOOD  21 

When  a  perforation  of  the  bowel  takes  place  in  typhoid  fever  there  may 
be  a  transient  increase  in  the  leukocytes,  and  in  rare  cases  the  leukocytosis 
is  high.  More  commonly  the  white  cells  increase  to  10,000  or  12,000, 
and  then,  particularly  in  unfavorable  cases,  their  numbers  fall  rapidly. 
Often  in  quickly  fatal  cases  it  is  impossible  to  detect  any  definite  rise  in 
the  leukocytes,  and  the  leukopenia  becomes  steadily  more  pronounced 
until  death. 

In  tuberculosis  a  leukocytosis  makes  its  appearance  only  when  a 
secondary  infection  is  engrafted  upon  the  original  process. 

A  few  non-inflammatory  conditions  may  give  rise  to  a  leukocytosis, 
and  unless  one  is  cognizant  of  this  fact,  confusion  may  arise.  Acute 
hemorrhage  is  followed  by  a  leukocytosis  which  is  often  very  pronounced, 
and  the  leukocytes  may  reach  as  much  as  20,000  per  c.mm.  Less 
marked  leukocytoses  are  seen  after  intoxications  by  certain  drugs,  such 
as  phenacetin  and  antipyrine,  and  after  chloroform  narcosis.  Occasionally 
a  leukocytosis  develops  during  the  course  of  such  malignant  tumors  as 
carcinoma  and  sarcoma. 

So  far  we  have  considered  only  the  leukocytoses  which  are  character- 
ized by  an  increase  in  the  polymorphonuclear  neutrophilic  cells,  but  it  is 
also  possible  to  have  a  leukocytosis  due  to  an  increase  in  the  eosinophile 
leukocytes.  Eosinophilia  occurs  in  a  number  of  conditions.  It  is  most 
marked  in  trichinosis  and  in  infections  by  certain  intestinal  parasites, 
particularly  the  ankylostoma  duodenale.  Eosinophilia  may  also  appear 
during  certain  stages  of  bronchial  asthma,  and  may  be  present  in  pemphi- 
gus and  some  varieties  of  skin  diseases. 

The  study  of  the  white  cells  of  the  blood  in  the  diseases  which  we  have 
mentioned  so  far,  though  it  may  suggest  or  aid  a  diagnosis,  is  not  essential 
for  the  diagnosis.  In  a  few  diseases  the  diagnosis  cannot  be  made 
without  a  blood  examination. 

The  diagnosis  in  leukemia  must  rest  entirely  upon  a  study  of  the  blood. 
There  are  two  main  forms  of  leukemia,  lymphatic  leukemia  and  myelo- 
genous leukemia. 

Lymphatic  leukemia  may  again  be  divided  into  two  types,  the  acute 
and  the  chronic.  In  acute  lymphatic  leukemia  the  clinical  picture  is 
usually  that  of  an  acute  infection  with  fever  and  general  prostration. 
The  lymph  glands  are  not  enlarged,  as  a  rule.  The  leukocytes  are  in- 
creased. They  may  number  50,000  to  200,000  or  more.  The  stained 
smear  shows  an  enormous  preponderance  of  a  form  of  large  lymphocytes. 
The  chronic  variety  is  characterized  by  an  enlargement  of  the  lymph 
glands  and  spleen  and  by  a  leukocytosis  in  which  the  white  cells  may 
reach  from  100,000  to  500,000  per  c.mm.  In  smears  the  cell  which  forms 
from  80  per  cent,  to  95  per  cent,  of  all  the  white  corpuscles  is  the  small 
lymphocyte.  In  both  types  the  red  blood  corpuscle  and  hemoglobin 
may  be  decreased,  but  anemia  is  usually  most  marked  in  the  acute  leuke- 
mias. 

Myelogenous  leukemia  is  characterized  by  enlargement  of  the  spleen, 
and  sometimes  of  the  lymph  glands,  with,  again,  a  great  increase  in  the 
numbers  of  white  blood  corpuscles.     Anemia  is  also  present,  and  the 


22  LABORATORY  DIAGNOSIS 

proportion  of  white  and  red  cells  may  be  1  to  5  or  1  to  3,  or  even  1  to  1. 
The  stained  smear  shows  a  variety  of  cells  which  are  not  normally  found 
in  the  blood.  Neutrophilic  and  eosinophilic  myelocytes,  cells  which 
normally  are  seen  only  in  the  bone  marrow,  form  a  large  percentage  of  the 
cells.  Nucleated  red  blood  corpuscles  may  also  be  seen  in  large  numbers. 
A  blood  examination  is  imperative  in  every  patient  who  has  marked 
enlargement  of  the  spleen  and  general  marked  enlargement  of  the 
lymph  glands. 

Besides  the  examination  of  the  formed  elements  of  the  blood,  one  may 
obtain  much  information  through  other  methods.  It  is  known  that  when  a 
culture  of  a  given  bacterium,  for  instance  the  typhoid  bacillus,  is  injected 
in  non-fatal  doses  into  an  animal,  the  serum  of  that  animal  gradually 
develops  the  property,  when   brought   into  contact  with  a  suspension 

Fig.  1 


Positive  agglutination  reaction. 

of  cultures  of  that  specific  organism,  of  causing  the  bacteria  to  clump 
together  in  great  masses.  This  is  known  as  agglutination,  and  the  serum 
may  develop  such  high  agglutinative  properties  that  it  will  be  active 
when  diluted  100,  1000,  or  even  10,000  times.  During  the  course  of 
typhoid  fever  the  serum  develops  the  power  of  agglutinating  the  typhoid 
bacillus,  and  this  specific  agglutinative  reaction  (the  Widal  reaction)  is 
made  use  of  for  the  diagnosis  of  this  disease.  In  order  to  say  certainly 
that  the  Widal  reaction  is  positive,  the  blood  serum  of  a  patient,  diluted 
at  least  fifty  times  and  better  one  hundred  times,  must  stop  the  motion  of 
the  typhoid  bacilli  and  cause  them  to  form  well  defined  clumps  within 
one  hour  (Fig.  1).  The  reaction  is  rarely  present  before  the  second  week 
of  the  disease,  and  may  be  delayed  until  the  end  of  the  third  or  fourth 
week.     Serum  from  patients  suffering  from  certain  other  bacterial  infec- 


EXAMINATION  OF  THE  URINE  23 

tions,  such  as  Malta  fever  or  tuberculosis,  may  develop  the  power  to 
agglutinate  the  infecting  organisms,  though  the  reaction  which  is  of  most 
practical  importance  is  that  occurring  in  typhoid  fever. 

Another  very  valuable  serum  reaction  for  diagnosis  is  the  complement 
deviation  method  of  Wasserman.  By  a  technique  which  is  complicated 
and  much  more  elaborate  than  that  of  the  Widal  reaction,  it  is  possible 
to  obtain  this  deviation  of  the  complement  of  the  blood  serum  in  a  large 
percentage  of  syphilitics.  The  reaction  usually  fails  when  the  patient 
has  been  treated  for  some  time  by  antisyphilitic  measures.  The 
reaction  depends  upon  the  union  of  a  specific  antibody  present  in  the 
serum  of  the  syphilitics  with  a  so-called  antigen  which  is  present  in 
tissue  richly  infected  with  Spirocheta  pallida.  Recently,  lecithin  has 
been  substituted  for  the  syphilitic  tissue.  During  the  union  of  the 
antibody  and  antigen  the  thermolabile  complement  of  serum  is 
absorbed.  The  same  method  of  diagnosis  has  been  applied  to  the 
serum  of  typhoid  and  tuberculous  patients,  an  extract  of  the  typhoid 
bacillus  and  tuberculin  being  used  as  antigen. 

More  accurate  information  may  be  received  in  systemic  bacterial 
infections  from  blood  cultures.  Small  amounts  of  blood  may  be  readily 
withdrawn  by  means  of  a  syringe  from  the  veins  at  the  elbow,  and  cul- 
tures may  be  made  from  this  blood  on  different  media.  This  method 
is  of  great  value  for  diagnosis  in  the  early  stages  of  typhoid  fever,  when 
typhoid  bacilli  may  be  obtained  in  80  to  95  per  cent,  of  the  cases.  Septi- 
cemia due  to  the  pyogenic  cocci  or  other  bacteria  may  often  be  discovered 
by  this  means;  or  when  the  diagnosis  is  suspected  it  may  be  confirmed 
and  the  nature  of  the  infecting  organism  accurately  determined. 

Finally,  it  is  necessary  to  mention  the  aid  which  may  be  given  by  an 
examination  of  the  blood  for  parasites.  The  discovery  of  the  malarial 
Plasmodia  may  explain  the  presence  of  alarming  chills,  while  it  is  not 
necessary  to  emphasize  the  importance  of  a  search  for  the  embryos  of 
Filiaria  sanguinis  hominis  in  cases  of  lymph  scrotum  and  chyluria,  for 
Spirillum  obermeieri  when  relapsing  fever  is  suspected,  and  in  rare 
instances  for  trypanosomes. 


EXAMINATION  OF  THE  URINE. 

Under  normal  conditions  an  adult  passes  from  1500  to  2000  c.c.  of 
urine  in  twenty-four  hours.  This  quantity  varies  slightly  in  health, 
according  to  the  amount  of  fluid  taken  into  the  body  or  the  amount  of 
fluid  lost  through  sweating,  etc.  Under  pathological  conditions  the 
amount  of  urine  may  vary  enormously.  It  is  increased  in  diabetes 
mellitus  and  diabetes  insipidus,  in  certain  forms  of  chronic  nephritis, 
and  in  certain  nervous  disorders,  while  the  amount  is  decreased  princi- 
pally in  acute  nephritis  and  certain  forms  of  chronic  nephritis. 

In  recurring  occlusion  of  the  ureters  through  any  cause,  or  in  certain 
forms  of  hydronephrosis,  the  quantity  of  urine  may  vary  from  time  to 
time.     The  periods  in  which  the  ureters  are  partially  blocked  are  char- 


24  LABORATORY  DIAGNOSIS 

acterized  by  decreased  urinary  secretion,  while  relief  of  the  block  is 
followed  by  marked  and  often  sudden  polyuria. 

The  specific  gravity  of  the  mixed  twenty-four-hour  urine  from  healthy 
persons  usually  lies  between  1015  and  1020.  After  the  drinking  of  much 
water  or  beer  the  specific  gravity  may  fall  to  1002,  or  after  excessive 
sweating  rise  to  1035.  As  a  general  rule,  in  diseased  states  the  specific 
gravity  of  the  urine  varies  with  the  quantity  of  urine  excreted.  A  con- 
centrated urine  has  a  high  specific  gravity,  while  in  polyuria  the  specific 
gravity  is  low.  There  is  one  glaring  exception.  In  the  marked  polyuria 
of  diabetes  mellitus  the  specific  gravity  is  greatly  increased,  and  may  be 
1040  to  1050. 

The  urine  from  a  normal  person  is  quite  transparent  and  varies  in  color 
from  a  pale  yellow  to  a  dark  amber.  On  standing,  a  flocculent  cloud 
forms,  which  is  composed  of  mucus  enclosing  a  few  cells.  A  precipitate 
of  urates  or  phosphates  or  a  growth  of  bacteria  may  cloud  the  urine 
diffusely.  Certain  characteristic  changes  in  the  color  are  seen  in  disease. 
In  febrile  states  the  urine  becomes  dark  yellow  or  reddish;  blood,  of 
course,  imparts  a  red,  smoky  appearance,  while  bile  produces  a  yellow 
or  greenish  tinge,  particularly  noticeable  in  the  foam.  Besides  these 
commoner  causes,  certain  drugs  give  rise  to  colored  urine.  Injection 
of  carbolic  acid,  hydrochinone,  and  salol  produce  a  dark  brown  or 
olive-green  urine;  rhubarb  and  senna  give  a  yellow  color,  due  to 
chrysophanic  acid;  santonin  gives  either  yellow  or  green;  while  methylene 
blue  produces  a  deep  blue  or  green  coloration. 

The  reaction  of  freshly  voided  normal  urine  is  slightly  acid,  due  to  the 
presence  of  several  acid  salts,  the  most  important  of  which  is  diacid 
sodium  phosphate.  The  acidity  varies  in  health  according  to  the  type 
of  diet,  becomes  more  marked  when  there  is  increased  consumption  of 
proteid,  less  marked  on  a  vegetable  diet,  and  during  difl^erent  periods 
of  the  day.  Immediately  after  meals  the  acidity  is  lowest.  The  acidity 
is  diminished  or  the  urine  becomes  alkaline  under  a  variety  of  circum- 
stances, but  most  noticeably  in  the  condition  known  as  phosphaturia, 
or  when  it  is  mixed  with  blood  or  alkaline  secretions,  or  when  alkaline 
fermentation  takes  place  anywhere  in  the  urinary  tract.  The  alkaline 
reaction,  if  it  is  due  to  ammonia,  is  caused  by  a  growth  of  certain  forms 
of  bacteria.  On  standing,  urine  from  normal  individuals  tends  to 
become  alkaline  through  bacterial  fermentation. 

Increase  in  the  acidity  is  rare,  though  it  may  occur  probably  as  the 
result  of  a  neurosis,  and  cause  symptoms  of  cystitis.  Cryoscopy,  or  the 
determination  of  the  freezing  point  of  the  urine,  may  give  information 
concerning  the  activity  of  the  kidneys.  A  freezing  point  above  0.9° 
indicates  low  molecular  concentration,  and  shows  that  the  functional 
activity  of  the  kidneys  is  interfered  with.  The  value  of  this  method  for 
determining  the  relative  activities  of  the  two  kidneys  from  an  examination 
of  the  urine  obtained  by  ureteral  catheterization  is  not  unquestionable. 

The  presence  of  albumin  in  the  urine  is  spoken  of  as  albuminuria,  and 
the  commonest  and  most  important  form  of  albumin  found  is  serum 
albumin.     The  finding  of   albumin   in  the  urine  may  denote  that  the 


EXAMINATION  OF  THE  URINE  25 

kidneys  have  failed,  at  least  partially,  in  their  function  as  filters,  thus 
allowing  the  passage  of  albumin  from  the  blood  (renal  albumin),  or  it 
may  point  to  the  presence  of  blood  or  pus  in  the  bladder  or  kidneys  or 
an  admixture  of  seminal  or  prostatic  fluids  with  the  urine  (accidental 
albuminuria). 

If  the  albumin  is  renal  in  origin,  it  is  safe  at  least  to  suspect  disease 
of  the  kidneys.  There  is,  however,  a  group  of  very  interesting  cases  in 
which  albuminuria  may  occur  in  persons  enjoying  apparently  perfect 
health.  This  physiological  albuminuria  may  occur  under  a  great 
variety  of  circumstances.  Albuminuria  may  be  present  in  the  urine  of 
healthy  pregnant  women,  in  men  after  severe  exertion,  as  in  bicycle 
riders  or  football  players,  after  mental  exertion,  cold  baths,  and  certain 
other  conditions.  It  is  still  dubious  as  to  whether  the  cyclical  and 
orthostatic  albuminurias  are  truly  functional,  and  appear  in  persons 
who  have  healthy  kidneys. 

Albuminuria  occurs  in  most  febrile  diseases,  when  there  is  a  degenera- 
tion of  the  epithelium  of  the  renal  tubules,  in  acute  and  chronic  conges- 
tion of  the  kidneys,  as  in  heart  disease,  and  in  all  forms  of  acute  and 
chronic  nephritis.  In  certain  forms  of  acute  nephritis  the  albumin 
may  be  present  in  large  quantities  and  measure  as  much  as  1  to  2  per  cent, 
when  estimated  in  the  Esbach  tubes,  whereas  in  certain  forms  of  chronic 
nephritis  there  may  be  only  0.1  per  cent,  to  0.5  per  cent.,  or  the  albumin 
may  only  be  present  in  traces.  In  amyloid  diseases  2  to  3  per  cent, 
of  albumin  may  be  present  in  the  urine. 

In  suppurative  conditions  of  the  kidneys  the  albumin  comes  both 
from  the  red  blood  cells  and  leukocytes  of  the  pus,  and  from  the  kidneys 
themselves.  Albumin  is  present  in  considerable  quantity,  and  usually 
amounts  to  more  than  0.1  per  cent.  In  inflammatory  conditions  of  the 
bladder,  however,  though  albumin  is  practically  present  in  every  severe 
case,  it  rarely  exceeds  more  than  0.1  per  cent,  to  0.15  per  cent,  in  amount 
unless  blood  is  present.  If,  therefore,  in  acute  inflammatory  conditions 
of  the  urinary  tract  the  amount  of  albumin  in  the  urine,  which  does  not 
contain  blood,  exceeds  0.2  per  cent.,  one  may  suspect  immediately  that 
one  or  both  kidneys  is  involved. 

Though  peptones  and  albumosis  may  appear  in  the  urine  when  there 
is  long-continued  suppuration  in  one  part  of  the  body,  the  presence  of 
these  bodies  is  not  of  any  great  diagnostic  significance. 

On  the  other  hand,  the-  presence  of  Bence  Jones'  body,  which  is  now 
known  to  be  related  more  closely  to  the  albumins  than  albumoses,  points 
at  once  to  a  disease  of  the  bone  marrow,  and  suggests  above  all  other 
things,  those  curious  tumors  called  multiple  myelomata.  The  body  has 
been  found  once,  in  another  dise^e,  namely,  lymphatic  leukemia. 

Nucleo-albumin,  a  body  allied  to  mucin,  has  no  practical  significance. 
Unless  the  test  for  albumin  is  carefully  made,  nucleo-albumin  may  be 
mistaken  for  true  serum  albumin. 

Fibrin  is  found  in  the  urine  very  rarely,  and  is  usually  associated  with 
chyluria,  a  condition  arising  during  the  course  of  certain  cases  of  filariasis, 
and  in  diphtheritic  inflammation  of  the  urinary  tract. 


26  LABORATORY  DIAGNOSIS 

Abnormal  excretions  of  glucose  may  occur  in  two  great  classes  of  cases  : 

(1)  Persons  suffering  from  a  definite  disease,  diabetes  mellitus,  and 

(2)  persons  who  have  transient  glycosuria. 

The  constant  presence  of  sugar  in  the  urine  means  diabetes  mellitus. 
In  quantity  the  sugar  may  vary  from  traces  to  10  per  cent.  During 
twenty-four  hours  a  patient  may  excrete  200  to  300  grams  of  glucose. 
In  mild  cases  the  glucose  disappears  or  decreases  markedly  when  car- 
bohydrates are  excluded  from  the  patient's  diet.  If  this  does  not  occur 
the  prognosis  is  bad. 

Transient  glycosuria  may  be  of  no  moment.  It  may  occur  after 
ingestion  of  sugar  in  abnormal  amounts,  in  certain  diseases  or  injuries 
to  the  nervous  system  and  digestive  tract,  after  insults  or  injuries  to  the 
liver,  after  fracture  of  the  long  bones,  after  ether  anesthesia,  in  exoph- 
thalmic goitre,  and  after  the  use  of  certain  drugs.  Injuries  to  the  pancreas 
may  give  rise  to  glycosuria,  while  in  certain  diseases  of  the  pancreas, 
such  as  severe  chronic  interstitial  pancreatitis,  glycosuria  may  at  first  be 
transient  and  later  become  constant. 

Acetone  is  found  in  the  urine  in  many  conditions,  but  has  most  sig- 
nificance in  diabetes  mellitus,  when  its  presence  may  indicate  ap- 
proaching coma.  It  appears  also  in  fevers,  during  starvation,  after  a 
purely  proteid  diet,  in  the  cachexias  due  to  malignant  tumors,  after 
chloroform  narcosis,  in  auto-intoxications,  certain  digestive  disturbances, 
and  cyclic  vomiting. 

Diacetic  acid  occurs  under  much  the  same  conditions  as  acetone,  and 
has  the  same  significance  in  diabetes  mellitus. 

/?-oxybutyric  acid  occurs  in  diabetic  coma,  and  its  presence  in  the  urine 
in  any  quantity  in  diabetes  mellitus  signifies  almost  certainly  approaching 
coma. 

When  blood  appears  in  the  urine,  one  speaks  of  hematuria;  when  the 
coloring  matter  without  the  cells  is  present,  the  condition  is  known  as 
hemoglobinuria.  In  hematuria  the  blood  may  come  from  the  kidneys, 
the  ureter,  the  bladder,  or  the  urethra. 

Renal  hematuria  may  be  caused  by  injury  to  the  kidneys.  It  may 
appear  when  there  is  a  stone  in  the  kidney,  in  acute  inflammation  of  the 
kidneys,  during  the  course  of  acute  or  chronic  nephritis,  when  the  kidneys 
are  the  seat  of  tumor  growth,  especially  hypernephroma,  in  purpura 
hemorrhagica,  in  chronic  passive  congestion  of  the  kidneys,  after  carbolic 
acid  poisoning,  occasionally  in  acute  infectious  diseases,  such  as  typhoid 
and  smallpox,  occasionally  in  leukemia,  or  finally,  in  parasitic  disease  of 
the  kidneys.  There  is,  besides,  a  primary  renal  hematuria,  the  cause  of 
which  is  not  definitely  determined.  Acute  inflammation  of  the  ureter 
(often  caused  by  the  passage  of  a  stone),  bladder,  prostate,  and  urethra 
may  cause  hematuria.  Tumors  of  the  bladder  frequently  give  rise  to 
severe  hematuria. 

Hemoglobinuria  is  seen  after  the  ingestion  of  certain  poisonous  sub- 
stances, such  as  potassium  chlorate  and  pyrogallic  acid,  after  the  trans- 
fusion of  foreign  blood,  or  even  after  the  transfusion  of  large  quantities 
of  blood  of  the  same  species,  in  extensive  burns,  in  black-water  fever, 
and  in  the  curious  condition  termed  paroxysmal  hemoglobinuria. 


EXAMINATION  OF  THE  URINE  27 

Melanin  in  the  urine  may  point  to  the  presence  of  a  melanotic  tumor 
of  the  kidney. 

The  bile  pigment,  bilirubin,  is  found  in  the  urine  when  there  is  obstruc- 
tion to  the  bile  passages,  and  is,  of  course,  always  present  in  jaundice. 
Indican  and  indigo  are  found  in  excess  in  the  urine  during  excessive 
putrefaction  of  proteid  material  in  the  intestinal  tract.  Indican  in  the 
urine  occurs  during  interstitial  disturbances  and  particularly  in  obstruc- 
tion. When  the  obstruction  is  in  the  small  bowel,  the  amount  of  indican 
is  much  greater  and  appears  much  sooner  than  when  the  obstruction 
is  in  the  large  intestine.  Leucin  and  tyrosin  are  the  decomposition 
products  of  albumin  and  are  found  in  the  urine,  and  in  such  destructive 
lesions  of  the  liver  as  acute  yellow  atrophy. 

The  color  reaction  described  by  Ehrlich  as  the  diazo  reaction  may  be 
obtained  in  at  least  95  per  cent,  of  all  cases  of  typhoid  fever.  Unfor- 
tunately the  reaction  is  not  specific,  for  it  may  occasionally  be  noted 
in  the  urines  from  cases  of  tuberculosis,  pneumonia,  septicemia,  and 
carcinoma. 

The  test  devised  by  Cammidge  is  said  to  be  specific  for  diseases  of  the 
pancreas,  and  is  thought  to  be  especially  valuable  for  the  diagnosis  of 
chronic  inflammation  of  the  pancreas. 

Bacteriology. — The  urine  in  the  normal  bladder  is  sterile,  but  since  it 
forms  a  good  culture  medium,  soon  after  it  is  passed  bacteria  rapidly 
develop  in  it.  During  the  course  of  certain  bacterial  diseases,  in  which 
there  is  a  septicemia,  the  infecting  bacteria  may  be  eliminated  in  the  urine. 
When  the  bacteriuria  is  renal  in  origin,  the  organisms  most  commonly 
found  are  typhoid  and  colon  bacilli.  The  typhoid  bacilli  can  be  grown 
from  the  urine  in  20  to  30  per  cent,  of  cases  of  typhoid  fever.  The 
bacilluria  may  continue  for  some  time  after  convalescence,  and  it  may 
be  present  without  setting  up  a  cystitis.  Bacteriuria  may  also  be  per- 
sistent in  cases  of  localized  infection  of  the  prostate  and  posterior 
urethra. 

Cultures  from  the  urine  from  cases  of  inflammation  of  the  urinary 
tract  may  help  to  elucidate  the  condition.  The  bacteria  which  are  most 
commonly  associated  with  cystitis  and  inflammation  of  the  ureters  and 
kidneys  are  Bacillus  coli.  Bacillus  proteus,  staphylococci,  streptococci, 
pneumococci,  gonococci,  and  the  tubercle  bacillus.  If  the  urine  contains 
pus  which  is  sterile  and  in  which  no  bacteria  can  be  seen  with  ordinary 
stains,  tuberculosis  may  be  suspected.  Great  care  should  be  observed 
in  differentiating  the  tubercle  bacillus  from  the  smegma  bacillus.  To 
make  a  positive  diagnosis,  the  urine  should  be  inoculated  into  guinea- 
pigs. 

Parasites  of  Urine  .^ — In  echinococcus  diseases  of  the  kidneys  or  bladder 
the  urine  may  contain  echinococcus  booklets  or  scolices.  Chyluria  may 
be  associated  with  filariasis,  so  that  if  chyluria  is  observed  in  any  case,  the 
urine,  but  more  especially  the  blood,  should  be  searched  carefully  for 
filaria  embryos.     The  diagnosis  may  be  made  solely  by  this  means. 

The  urine  in  Egyptian  hematuria  often  contains  the  eggs  of  the  para- 
site Distomum  hematobium,  which  produces  the  disease. 


28  LABORATORY  DIAGNOSIS 


EXAMINATION  OF  THE  FECES. 

The  frequency  and  the  amount  of  defecation  in  health  vary  so  greatly 
with  the  individual  and  depends  upon  so  many  factors  that  departures 
from  normal  are  often  not  noted  until  they  have  become  pronounced. 

The  consistency  of  the  fecal  mass  depends  upon  the  amount  of  water 
which  it  contains.  An  increase  of  fluid  may  be  caused  either  by  an 
increased  exudation  or  transudation  from  the  intestinal  mucous  mem- 
brane, or  by  decreased  absorption  of  water  by  the  intestinal  walls.  An 
exudation  of  fluid  takes  place  in  inflammation  of  the  mucous  membrane, 
while  decreased  absorption  may  occur  when  peristalsis  is  for  any  reason 
increased. 

Some  information  may  be  gained  from  the  color  of  the  stools.  Varia- 
tions in  color  may  depend  upon  (1)  digestive  secretions;  (2)  food  residue; 
(3)  discharges  from  the  intestinal  mucous  membrane;  (4)  accidental 
ingredients,  such  as  drugs. 

The  secretion  which  is  of  most  importance  in  giving  a  color  to  the 
intestinal  contents  is  bile,  and  the  coloring  matter  is  a  derivative  of 
bilirubin,  namely,  hydrobilirubin  or  urobilin.  After  the  first  few  months 
of  life,  biliverdin  and  bilirubin  are  not  present  in  the  normal  stool. 

If  the  stools  are  free  from  bile  pigmentation,  a  condition  which  occurs 
in  complete  occlusion  of  the  bile  ducts,  they  exhibit  a  pale  color,  the 
typical  clay-colored  stools. 

In  many  diarrheas  the  stools  may  contain  bilirubin,  owing  to  the  fact 
that  the  stool  is  so  rapidly  carried  through  the  intestinal  canal  that  there 
has  not  been  time  to  convert  these  substances  into  hydrobilirubin. 
These  pigments  give  to  the  stool  a  yellow  color  and  in  infants  the  fre- 
quent admixture  of  biliverdin  with  the  bilirubin  gives  to  the  stool  the 
characteristic  green  color.  The  green  stools  of  infants  may  also  be 
dependent  upon  the  growth  of  such  chromogenic  bacteria  as  Bacillus 
pyocyaneus. 

The  food  residue  has  also  much  to  do  with  the  color  of  the  stools. 
With  a  vegetable  diet  the  stools  are  usually  lighter  in  color  than  with  a 
meat  diet,  whereas  a  milk  diet  produces  a  yellow  or  greenish-white  stool. 
The  coloring  matter  of  certain  fruits  may  give  a  dark-brown  or  greenish- 
black  color  to  the  feces,  which  without  careful  examination  may  be  mis- 
taken for  digested  blood. 

Such  discharges  from  the  intestinal  wall  as  mucus,  pus,  and  serum 
rarely  produce  any  definite  coloration,  though  large  quantities  of  mucus 
may  impart  a  glassy  or  glistening  appearance  to  the  stool.  Blood  always 
changes  the  color  of  the  stool  if  present  in  any  quantity.  The  color 
depends  much  upon  the  length  of  time  the  blood  has  been  in  the  intestines, 
and  varies  from  bright  red  in  fresh  hemorrhages  to  a  tarry  black  in  old 
hemorrhages. 

Among  the  drugs,  bismuth  is  the  most  important  coloring  agent.  After 
the  use  of  this  drug  the  stools  are  colored  gray  or  black  from  the  presence 
of  bismuth  sulphide. 


EXAMINATION  OF  THE  FECES 


29 


Small  amounts  of  fat  demonstrable  microscopically  either  as  neutral 
fat  or  as  fatty  acid  crystals  may  appear  in  the  stools  in  a  number  of  condi- 
tions. Large  amounts  of  fat  in  the  form  of  fatty  acid  crystals  give  to  the 
evacuation  an  exceedingly  pale  color,  while  neutral  fat  may  be  present 
in  such  quantities  that  the  stool  is  surrounded  or  covered  with  a  yellow 
oily  substance. 

When  the  flow  of  bile  into  the  intestinal  tract  is  cut  off,  a  large  per- 
centage of  the  ingested  fat  is  not  completely  split  up,  and  the  stools  may 
contain  great  quantities  of  fatty  acid  crystals  (Fig.  2).  When  the 
absorption  of  fat  is  impeded  by  blocking  of  the  intestinal  lymphatics, 
such  as  may  occur  in  tabes  mesenterica,  fat  may  also  be  present  in  the 
feces.  A  very  important  condition  in  which  fatty  stools  may  appear  is 
disease  of  the  pancreas.     Fatty  stools  are  by  no  means  constantly  seen 

Fig.  2 


'hyxy> 


Forms  of  fats  and  soaps  in  stools  (Schmidt  and  Strassbuiger).  a,  soaps;  h,  casein  and  fat 
globules;  c,  fatty  acid  needles  and  leukocytes;  d,  yellow  calcium  soap;  e,  fatty  acid  crystals 
projecting  from  fat  droplets;  j,  fatty  acid  and  soap  needles  and  scales  from  an  acholic  stool. 


in  cases  of  chronic  pancreatitis  or  in  obstruction  of  the  pancreatic  duct, 
but  they  may  occur,  and  the  amount  of  fat  may  be  large.  Free  fat  may 
be  passed  in  great  amounts  in  chronic  pancreatitis,  surrounding  the  stool 
or  covering  it  like  melted  butter. 

In  alcoholics  the  stools  may  also  be  pale,  due  partly  to  the  presence  of 
fat,  but  principally  to  the  transformation  of  the  normal  coloring  matter, 
hydrobilirubin,  into  a  colorless  substance. 

Visible  mucus  may  appear  in  the  stool  in  various  forms  of  catarrhal 
inflammation  of  the  intestines.  Typical  long  shreds,  membrane-like 
pieces  of  mucus,  or  even  casts  of  the  intestines  may  be  found  in  the  stools 
in  mucous  colitis.  Small  glairy  pieces  of  mucus  are  found  in  great 
amounts  in  diphtheritic  dysentery  and  in  amebic  colitis.  In  both 
diphtheritic  dysentery  and  amebic  colitis  the  bowel  movements  may  be 
composed  almost  exclusively  of  mucus,  blood,  leukocytes,  and  bacteria, 

The  presence  of  blood  in  the  stools  points  naturally  to  a  hemorrhage. 
Large  hemorrhages  may  come  from  bleeding  hemorrhoids,  newgrowths 


30  LABORATORY  DIAGNOSIS 

of  the  intestines,  such  as  papilloma  or  carcinoma,  and  bleeding  typhoid, 
or  rarely  tuberculous  ulcers.  Hemorrhages  into  the  stomach  caused  by 
gastric  ulcers,  cirrhosis  of  the  liver,  or  splenomegaly  may  be  evidenced 
by  the  passage  of  copious  bloody  stools. 

By  the  newer  methods  of  examination  of  the  stools  for  occult  blood, 
small  quantities  not  recognizable  by  any  other  means  may  be  detected 
and  the  presence  of  some  form  of  ulceration  of  the  gastro-intestinal 
tract  determined.  By  this  means  it  can  be  shown  that  the  stools  contain 
occult  blood  in  many  cases  of  typhoid  fever,  in  ulcerations  of  the  intes- 
tines due  to  intestinal  parasites,  in  many  acute  inflammations  of  the 
intestinal  tract,  in  ulcerating  tumors  of  the  large  and  small  bowel,  and  in 
ulcers  of  the  stomach. 

When  an  abscess  ruptures  into  the  intestinal  tract,  pus  visible  to  the 
naked  eye  may  be  passed  by  the  bowel.  If  the  pus  is  evacuated  into 
the  bowel  high  up,  it  is  usually  mixed  with  feces,  and  when  it  is  passed 
has  undergone  such  alterations  that  it  is  rarely  recognizable,  except  by 
the  microscope.  Great  numbers  of  leukocytes  may  be  found  in  the  feces 
in  various  forms  of  intestinal  ulceration,  due  to  newgrowths,  typhoid 
fever,  or  tuberculosis  and  amebic  or  bacillary  dysentery.  In  acute  forms 
of  amebic  dysentery,  as  well  as  bacillary  dysentery,  small  masses  of  pus 
may  be  seen  by  the  naked  eye,  mixed  with  mucus  or  blood. 

Occasionally  small  particles  of  a  tumor  are  discovered  in  the  feces,  and 
when  carcinoma  of  the  intestines  is  suspected  a  careful  search  of  the  feces 
may  show  bits  of  tissue  which  on  microscopic  examination  prove  to  be 
masses  of  newgrowth.  If  one  is  successful  in  finding  such  particles,  the 
correct  diagnosis  can  be  arrived  at  with  certainty. 

Gallstones,  pancreatic  stones,  and  intestinal  stones  are  occasionally 
found  in  the  feces.  Since  gallstones  are  quite  frec(uently  passed  in  the 
feces,  an  examination  of  the  stools  should  be  made  in  all  cases  of  sus- 
pected cholelithiasis.  The  presence  of  cholesterin  in  a  stone  stamps  it 
as  coming  from  the  gall-bladder.  Pancreatic  stones  are  rare.  They 
may  be  identified  by  the  fact  that  they  are  composed  of  calcium  car- 
bonate.   The  enteroliths  are  formed  principally  of  phosphates. 

Bacteriological  examination  of  the  stool  is  attended  with  many  diflfi- 
culties,  though  it  may  aid  materially  in  the  diagnosis  of  an  intestinal 
disease.  In  typhoid  fever,  typhoid  bacilli  may  be  grown  from  the  stools 
in  quite  a  large  proportion  of  cases.  It  should  be  remembered  that 
patients  may  continue  to  eliminate  typhoid  bacilli  for  months  or  years 
after  an  attack  of  typhoid  fever.  It  is  probable  that  in  the  chronic 
bacillus  carriers  the  bacilli  come  really  from  the  gall-bladder,  which  acts 
as  a  reservoir  and  allows  of  the  entrance  of  innumerable  typhoid  bacilli 
into  the  intestinal  contents.  Tubercle  bacilli  are  found  in  the  stools  of 
persons  suffering  with  tuberculosis  of  the  intestinal  tract,  but  the 
finding  of  tubercle  bacilli  is  not  diagnostic  of  intestinal  ulceration,  since 
bacilli  which  have  been  swallowed  with  sputum  may  be  found  in  the 
feces. 

In  amebic  dysentery  the  amebse  are  most  numerous  and  most  readily 
seen  in  bits  of  mucus. 


EXAMINATION  OF  THE  SPUTUM  31 

The  diagnosis  of  an  infection  of  the  intestines  by  a  parasite  may  be 
made  solely  upon  the  discovery  of  ova  of  the  parasite  in  the  stool.     In 


Fig.  3 


V 


Eggs  of  parasites.     Uncinaria  americana. 


cases  of  anemia  the  stools  should  always  be  examined  for  parasites.  The 
parasites  which  most  commonly  cause  severe  anemia  are  Ankylostoma 
duodenale,  Bothriocephalus  latus,  and  Paramecium  coli  (Fig.  3). 


EXAMINATION  OF  THE  SPUTUM. 

An  examination  of  the  sputum  may'^be  of  material  benefit  in  assisting 
in  the  diagnosis  of  a  few  conditions  which  are  treated  by  the  surgeon, 
but  is  principally  valuable  in  offering  an  aid  to  the  better  understanding 
of  certain  surgical  complications. 

The  quantity  of  the  sputum  may  be  quite  small  in  many  pulmonary 
conditions,  but  occasionally  large  amounts  are  expectorated  in  twenty- 
four  hours.  This  is  seen  particularly  in  certain  forms  of  chronic  bron- 
chitis, in  bronchorrhea,  sometimes  in  pulmonary  tuberculosis,  in  bron- 
chiectasis, gangrene  and  abscess  of  the  lung,  perforation  of  an  empyema 
or  of  an  amebic  abscess  into  the  bronchi,  and  with  pulmonary  hemor- 
rhage. 

The  color  of  the  sputum  varies  greatly  according  to  the  disease.  In 
pneumonia,  especially  during  the  early  stages,  it  has  a  rusty  brown  tinge. 
Sputum  containing  pus  has  a  yellowish  white  or  greenish  tinge;  when 
mixed  with  blood,  it  is  red;  and  in  jaundice  it  is  yellow  or  green,  due  to 
the  presence  of  bile  pigments.  In  anthracosis  the  sputum  is  colored 
black  or  gray.  The  prune-juice  sputum  is  typical  of  the  discharge  of  an 
amebic  abscess  into  the  bronchi. 

The  odor  of  the  sputum  in  certain  cases  of  pulmonary  tuberculosis,  in 
abscess  and  gangrene  of  the  lung,  and  putrid  bronchitis  is  extremely  foul. 

Macroscopically  one  may  distinguish  mucus  by  its  stringy,  glairy 
appearance,  and  pus  by  its  opaque  yellowish  or  greenish  look.  Varying 
quantities  of  blood  are  seen  in  the  sputum  in  pneumonia,  in  pulmonary 
tuberculosis,  in  heart  disease,  and  in  infarction  of  the  lung.    In  the  last 


32 


LABORATORY  DIAGNOSIS 


two  conditions  large  quantities  of  blood  may  be  expectorated.  In  condi- 
tions such  as  abscess  and  gangrene  small  particles  of  lung  tissue  may 
be  found  which  appear  as  white,  green,  or  blackish  particles.  Cursch- 
man's  spirals,  readily  visible  to  the  naked  eye,  are  present  in  cases 
of  bronchial  asthma.  Fibrinous  casts  of  the  bronchi  may  be  found  in 
that  condition  known  as  fibrinous  bronchitis. 

Microscopically  the  presence  of  many  polymorphonuclear  leukocytes 
gives  evidence  of  an  acute  inflammation  of  the  bronchi  or  alveoli.  In 
bronchial  asthma  as  many  as  60  per  cent,  of  the  leukocytes  may  be 
eosinophilic.  Red  blood  corpuscles  may  occur  in  many  conditions. 
They  may  be  found  in  the  sputum  in  pneumonia,  especially  in  the  early 
stages,  in  heart  disease,  in  infarction  of  the  lung,  in  abscess,  and  in 
gangrene,  and  in  pulmonary  tuberculosis.  Elastic  fibers  signify  that 
alveoli  or  bronchi  are  being  destroyed,  and  may  be  found  in  abscess, 
gangrene,  bronchiectasis,  and  pulmonary  tuberculosis  (Fig.  4). 


Fig.  4 


Elastic  tissue  from  lung.      X  400. 


Charcot-Leyden  crystals  are  seen  in  the  sputum  in  bronchial  asthma 
when  they  are  found  associated  with  the  eosinophilic  leukocytes.  Fatty 
acid  crystals  are  often  seen  in  abscess  and  gangrene  of  the  lung. 
More  rarely  leucin  and  tyrosin  or  hematoidin  crystals  are  found. 

Two  animal  parasites  are  occasionally  seen  in  the  sputum.  When 
an  amebic  abscess  of  the  liver  ruptures  into  the  lung,  amebse  may  be 
found  in  the  sputum,  and  their  discovery  will  clinch  the  diagnosis.  In 
parasitic  hemoptysis,  ova  of  the  lung  fluke,  or  Distomum  pulmonale,  the 
parasite  which  causes  the  disease,  is  present  in  the  expectoration. 

The  presence  of  tubercle  bacilli  in  the  sputum  means  pulmonary 
tuberculosis,  and  naturally  in  every  case  suspected  of  having  tubercu- 
losis the  sputum  should  be  searched  most  carefully  for  these  bacteria. 
Repeated  examinations  in  many  instances  are  necessary  to  demonstrate 
their  presence. 

The  presence  of  great  quantities  of  pneumococci  in  the  sputum  is 


EXAMINATION  OF  THE  GASTRIC  CONTENTS  33 

evidence  of  pneumonia  or  of  some  pneumococcal  infection  of  the  respira- 
tory tract.  In  influenza,  both  acute  and  chronic,  the  sputum  may  be 
loaded  with  influenza  bacilli.  A  diagnosis  of  infection  by  this  organism 
may  be  made  from  an  examination  of  the  sputum.  Less  frequently  the 
Friedlander  bacillus,  Aspergillus  fumigatus  actinomyces,  the  glanders 
bacillus,  and  the  bacillus  of  plague  may  be  found  in  the  sputum.  No 
conclusions  can  be  drawn  from  finding  of  the  ordinary  pyogenic  cocci. 


EXAMINATION  OF  THE  GASTRIC  CONTENTS. 

Except  for  the  information  gained  from  a  general  or  perhaps,  in  cases 
of  poisoning,  from  a  chemical  examination  of  the  vomitus,  a  study  of 
this  material  gives  but  little  definite  knowledge  concerning  the  main 
underlying  disease.  By  general  inspection  one  may  determine  whether 
the  vomitus  contains  bile,  blood,  or  undigested  material.  The  odor  will 
indicate  roughly  the  presence  of  certain  drugs  or  poisons,  and  a  chemical 
analysis  will  yield  accurate  information. 

In  the  examination  of  the  test  meal  we  are  especially  anxious  to  know 
the  total  amount  of  acid,  the  amount  of  free  hydrochloric  acid,  the  amount 
of  pepsin  present,  and  as  to  whether  lactic  acid  is  or  is  not  present. 

Under  normal  conditions,  as  the  tests  are  carried  out  with  the  Ewald 
meal,  the  total  amount  of  acid  in  the  gastric  juice  varies  between  30  to 
70  (0.11  to  0.26  per  cent.),  while  the  amount  of  free  hydrochloric  acid 
varies  from  0.05  to  0.2  per  cent. 

In  a  general  way  one  may  say  that  the  total  amount  of  acid  is  increased 
in  gastric  ulcer  (in  which  condition  the  free  hydrochloric  acid  is  also 
increased),  in  simple  hyperacidity,  in  certain  nervous  conditions,  and  in 
the  early  stages  of  chronic  gastric  catarrh.  The  acidity  is  decreased 
among  other  conditions  in  many  anemic  states,  in  certain  gastric  neuroses, 
in  the  later  stages  of  chronic  gastric  catarrh,  and  in  many  cachexias. 
Free  hydrochloric  acid  is  found  wanting  in  gastric  cancer,  in  certain 
severe  infectious  diseases,  in  pernicious  anemia,  and  in  achylia  gastrica. 

Lactic  acid  is  found  in  carcinoma  of  the  stomach,  and  combined  with 
the  lack  of  free  hydrochloric  acid,  is  very  suggestive  of  this  disease. 

The  presence  of  occult  blood  in  the  test  meal  or  in  vomited  material 
may  be  significant  of  one  of  several  conditions.  Hemorrhage  into  the 
stomach  may  occur  in  gastric  ulcer,  carcinoma  of  the  stomach,  cirrhosis 
of  the  liver,  or  splenomegaly;  but  before  one  can  draw  any  conclusions 
from  the  finding  of  occult  blood,  it  is  necessary  to  exclude  with  great 
care  any  admixture  of  blood  from  the  mouth,  gums,  or  from  slight 
abrasions  of  the  esophagus  or  gastric  mucosa  when  the  stomach  tube  is 
used.  Of  great  importance  is  the  examination  of  any  small  bits  of 
tissue  which  may  occasionally  be  found  in  the  stomach  washings.  In 
cancer  of  the  stomach,  small  particles  of  the  tumor  may  be  washed 
away  during  lavage,  and  by  a  microscopic  examination  of  these  particles 
it  is  possible  to  establish  the  diagnosis  of  carcinoma. 

A  microscopic  examination  of  the  test  meal  will  reveal  starch  granules, 
3 


34  LABORATORY  DIAGNOSIS 

a  few  epithelial  cells,  fat  droplets,  yeast  fungi,  and  bacteria.  The  large 
bacteria,  the  Oppler-Boas  bacilli,  are  associated  with  the  presence  of  lac- 
tic acid  in  the  stomach  contents,  and  their  presence  suggests  carcinoma. 
Both  fresh  and  old  blood  may  be  seen,  especially  in  carcinoma  and  gastric 
ulcer.  Great  numbers  of  leukocytes  may  be  seen  in  certain  cases  of  acute 
gastritis  or  when  a  carcinoma  is  breaking  down  and  undergoing  second- 
ary inflammatory  changes. 

The  presence  of  food  eaten  the  day  before  the  stomach  is  emptied 
by  the  tube  points  to  retention  which  may  be  due  to  pyloric  stenosis, 
gastroptosis,  or  dilatation. 

EXAMINATION  OF  TRANSUDATES,  EXUDATES,  AND  SECRETIONS. 

Collections  of  transudated  fluid  removed  from  the  pleura,  the  peri- 
cardium, and  the  peritoneum  have  much  the  same  characteristics.  They 
usually  are  clear  yellow,  of  alkaline  reaction,  and  contain  albumin.  In 
pleural  transudates  there  may  be  many  endothelial  cells  in  the  centrifu- 
galized  sediment,  but  leukocytes  are  scarce  or  absent.  A  true  transudate 
is  always  sterile. 

Inflammatory  exudates  vary  in  character  according  to  the  infecting 
agent  which  produces  them.  Exudates  caused  by  the  pneumocccus, 
the  staphylococcus,  the  typhoid  bacillus,  and  the  tubercle  bacillus  often 
present  different  characteristics.  The  exudate  produced  by  the  strep- 
tococcus, staphylococcus,  pneumococcus,  and  sometimes  by  the  typhoid 
bacillus  is  frankly  purulent.  The  fluid  is  thick  and  white  or  yellow  in 
color.  Microscopic  examination  shows  that  by  far  the  greatest  number 
of  cells  are  polymorphonuclear  leukocytes,  and  smears  stained  in  gentian 
violet  will  reveal  the  infecting  microorganisms  in  great  numbers.  Some 
exudates  due  to  the  pneumococcus  and  typhoid  bacillus  are  seropurulent 
or  truly  serous,  containing  comparatively  few  cells.  If  the  specimen  is 
centrifugalized,  however,  in  the  sediment  it  will  be  found  that  the  cells 
which  are  present  are  of  the  polymorphonuclear  variety.  This  is  an 
important  differential  point  in  deciding  as  to  whether  a  serous  or  sero- 
fibrinous exudate  is  tuberculous  or  not. 

Tuberculous  exudates  are  almost  always  serofibrinous  in  character, 
though  they  may  contain  varying  amounts  of  blood,  while  rarely  the  pres- 
ence of  large  quantities  of  cells  gives  them  an  opaque  appearance.  It 
is  exceedingly  difficult  to  demonstrate  the  tubercle  bacillus  in  such  exu- 
dates. The  inoculation  of  animals  will  give  positive  results,  and  occa- 
sionally the  method  of  examination  designated  inoscopy,  in  which  the 
fibrinous  coagulum  is  digested,  the  digested  fluid  centrifugalized,  and  the 
sediment  stained  for  tubercle  bacilli,  will  show  the  presence  of  bacilli. 
But  a  simpler  method  of  differentiation  is  based  upon  the  type  of  cell 
which  is  present  in  these  exudates.  It  has  been  stated  that  in  exudates 
caused  by  the  pyogenic  cocci,  the  polymorphonuclear  leukocyte  is  the 
typical  cell.  In  tuberculous  exudates  this  cell  is  comparatively  scarce, 
and  the  majority  of  elements  are  mononuclear  cells.  In  tuberculous 
exudates  90  to  95  per  cent,  of  the  cells  may  be  small  mononuclears. 


EXAMINATIONS  OF  SECRETIONS  35 

True  hemorrhagic  exiuhites  are  seen  principally  in  tuberciilosi.s  and 
carcinoma  or  sarcoma.  Though  a  general  carcinosis  or  sarcomatosis 
of  the  pleiu'a  or  peritoneum  may  and  often  does  give  rise  to  hemorrhagic 
exudates,  in  certain  cases  the  aspirated  fluid  may  be  serous  in  appearance. 
The  presence  of  definite  tumor  cells  in  such  exudates  will  lead  to  the 
correct  diagnosis. 

The  examination  of  the  spinal  fluid  may  be  carried  out  in  much  the 
same  manner  as  the  examination  of  exudates  from  the  pleura,  pericardium, 
and  peritonum.  The  spinal  fluid  from  normal  individuals  contains  only 
traces  of  albumin  and  but  few  cells,  not  more  than  2  to  7  leukocytes  per 
c.mm.  The  exudates  are  serous,  serofibrinous,  seropurulent,  purulent, 
fibrinopirulent,  or  hemorrhagic.  The  meningococcus  gives  rise  to  a 
serous,  seropurulent,  or  fibrinopurulent  exudate.  The  characteristic 
cell  is  the  polymorphonuclear  leukocyte  containing  the  infecting  micro- 
organism. The  meningococcus  can  be  demonstrated  in  coverslips.  The 
pyogenic  cocci  produce  purulent  exudates,  and  the  typhoid  bacillus 
usually  serous  exudates. 

In  cases  of  tuberculous  meningitis  the  spinal  fluid  is  quite  character- 
istic, and  is  serous,  serofibrinous,  or  rarely  seropurulent.  The  type  of 
cell  which  is  found  is  the  same  as  that  seen  in  pleural  or  pericardial 
exudates — the  small  lymphocyte.  But  in  the  spinal  fluid  tubercle  bacilli 
may  be  demonstrated  in  practically  every  case  by  an  examination  of  the 
filmy  fibrin  clot  which  forms  in  most  fluids  withdrawn  from  the  meninges 
of  cases  of  tuberculous  meningitis. 

For  the  Wasserman  reaction  in  the  diagnosis  of  syphilis,  or  the  more 
recent  reaction  described  by  Noguchi,  the  spinal  fluid  is  even  more  useful 
than  blood  serum.  The  spinal  fluids  from  70  to  SO  per  cent,  of  cases  of 
tabes  and  dementia  paralytica  give  a  positive  reaction. 

It  is  almost  impossible  to  draw  any  conclusions  from  the  presence  of 
blood  in  spinal  fluid.  Bloody  fluids  may  be  found  in  cases  of  cerebral 
hemorrhage,  but  it  is  so  difficult  to  exclude  blood  which  may  be  due  to 
the  puncture  itself,  that  the  withdrawal  of  bloody  fluid  from  the  spinal 
canal  can  have  no  significance. 


EXAMINATIONS  OF  SECRETIONS,  FLUIDS  FROM  SCARIFIED 

SURFACES,  ETC. 

The  examination  of  any  abnormal  secretion  will  always  be  of  some  aid 
in  determining  the  character  of  the  pathological  process.  By  the  finding 
of  gonococci  in  the  urethral  or  vaginal  discharges  the  diagnosis  of 
gonorrhea  can  be  made  unhesitatingly  (Fig.  o).  In  discharges  from  the 
ear,  the  eye,  and  the  nose  careful  examination  will  determine  the  nature 
of  the  infecting  organism,  and  if  one  desires  to  treat  such  chronic  suppura- 
tive conditions  with  vaccines,  it  is  positively  essential  that  an  accurate 
diagnosis  of  the  infecting  bacteria  should  be  made,  and  that  the  vaccines 
should  be  prepared  from  growths  of  exactly  the  same  organism  which 
causes  the  trouble  in  that  particular  patient.     By  making  smears  from 


36  LABORATORY  DIAGNOSIS 

an  anthrax  pustule  the  disease  may  be  diagnosticated  with  certainty. 
The  typical  bacilli  are  often  found  in  great  numbers  in  coverslips. 

Since  the  discovery  of  the  Spirocheta  pallida  a  very  valuable  method  is 
now  at  hand  for  the  early  diagnosis  of  cases  of  syphilis.  The  spiro- 
chetse  are  found  in  the  chancre  and  in  practically  all  the  secondary  lesions 
of  syphilis  (Plate  III).  To  demonstrate  these  organisms,  it  is  necessary 
to  scarify  superficially  the  surface  of  the  chancre,  mucous  patch,  condy- 
loma, or  skin  lesion,  prepare  coverslips  from  the  exuding  serum,  which 
contains  little  or  no  blood,  and  stain  by  the  method  of  Giemsa  or 
Goldhorn,  or  by  the  newer  silver  method  described  by  Stern.  Smears 
may  be  prepared  and  stained  in  the  same  way  from  the  aspirated  juice 
of  an  enlarged  lymph  node.     The  spirochetse  may  be  present  in  fairly 

Fig.  5 


Gonococcus  in  pus  cells.       X  1100  diameters.      (Park.) 

large  numbers,  but  frequently  they  are  scarce  and  must  be  searched  for 
with  pains.  If  Spirocheta  pallida  can  be  demonstrated,  the  diagnosis 
of  syphilis  is  assured.  One  must  always  use  the  greatest  caution  in 
differentiating  Spirocheta  pallida  from  Spirocheta  refringens,  which  is 
frequently  found  in  non-specific  ulcers  and  erosions  of  the  external 
genitalia. 

A  method  which  is  even  more  valuable,  since  it  is  more  rapid,  is  to 
examine  fresh  material  obtained  in  much  the  way  as  described  above, 
under  a  microscope  furnished  with  the  new  form  of  condenser  that  throws 
the  rays  from  a  powerful  artificial  light  across  the  field  of  the  microscope. 
With  this  transillumination  the  spirochetse  appear  as  brilliant  twisting 
spirals  upon  a  black  background. 


PLATE  111 


V 


y^ 


J 


Cl 


Spirochaste  Pallida.     Smear  from  Hard  Chancre.     Giemsa's  stain. 
X  1000.      (Osier.) 


FIG.   2 


Spirochaste  Refringens.     Smear  from  Chancroid.     X   1000.     (Osier.) 


CHAPTEE    II. 

THE  APPLICATION  OP  THE  X-RAYS  IN  SURGICAL  DIAGNOSIS. 
By  H.  K.  PANCOAST,  M.D. 

The  maximum  efficiency  of  the  rc-rays  is  attained  and  the  minimum 
danger  incurred  only  when  the  apparatus  is  thoroughly  modern  and 
skilfully  handled  and  the  results  are  interpreted  by  one  familiar  with 
its  workings  and  trained  by  a  large  experience  to  recognize  the  correct 
meaning  of  the  different  shadows. 

With  very  few  exceptions  the  skiagraphic  examination  is  preferable  to 
that  by  the  fluoroscope.  The  latter,  even  in  the  hands  of  those  expert 
in  its  interpretations,  is  often  misleading. 

The  risks  involved  in  the  radiographic  examination  are  now  so  slight 
that  they  may  be  practically  disregarded. 

BONES  AND  JOINTS. 

The  interpretation  of  radiographs  taken  for  the  detection  of  affections 
of  the  bones  and  joints  involves  a  knowledge  of  the  normal  appearances 
and  variations  in  conformation  of  bones  and  joints  and  a  clear  conception 
of  epiphyseal  development  and  union  in  relation  to  age. 

Fractures. — When  the  ordinary  and  diagnostic  symptoms  of  fracture 
are  present,  the  a;-rays  are  serviceable  in  accurately  determining  the  nature 
and  extent  of  the  deformity,  the  interposition  of  soft  parts,  the  presence 
or  absence  of  comminution,  or  the  antecedent  pathological  condition 
predisposing  to  a  break. 

When  the  usual  signs  of  fracture  are  indistinct,  or  cannot  be  elicited 
because  of  tenderness  and  great  swelling,  the  x-ray  examination  is  indis- 
pensable. Under  this  heading  may  be  classed  most  incomplete  and 
impacted  fractures,  all  those  lying  in  the  joint  or  near  it,  fractures  of  the 
carpal  bones  and  proximal  ends  of  the  metacarpals,  of  the  tarsals  and 
metatarsals. 

Examination  of  a  patient  suffering  from  injury  in  the  neighborhood 
of  a  joint  cannot  be  regarded  as  complete  until  it  has  been  supplemented 
by  the  information  gained  by  the  skiagraph.  Many  of  the  bone  lesions 
cannot  possibly  be  diagnosticated  in  any  other  way,  and  in  some,  as 
instanced  by  an  impacted  fracture  of  the  femoral  neck,  manual  diag- 
nostic efforts  are  distinctly  contra-indicated. 

The  ic-rays  give,  without  pain  or  added  trauma,  complete  information 
in  regard  to  the  presence  of  fracture,  its  seat,  its  nature,  and  the  direction 
and  degree  of  deformity. 


38       THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

When  a  skiagraph  is  taken  for  diagnostic  purposes,  all  dressings  should 
be  removed,  if  this  be  practicable,  since  all  are  obscuring  to  an  extent, 
and  some  unexpectedly  so  to  the  inexperienced.  Thus,  lead  water,  bichlor- 
ide of  mercury  solution,  iodoform,  ointments  containing  metallic  salts, 
starch  bandages,  and  plaster  all  interfere  with  the  production  of  clear 
pictures.  Nevertheless,  the  best  interests  of  the  patient  may  require  a 
picture  to  be  taken  under  circumstances  other  than  those  most  favorable. 
Though  clear  definition  is  essential  to  the  determination  of  certain 
bone  lesions,  it  is  not  usually  required  in  the  gross  diagnosis  of  fracture. 

In  cases  of  fracture  without  adequate  cause  the  x-rays  afford  the  only 
means  of  framing  a  diagnosis  of  the  underlying  bone  affection,  as,  for 
example,  cyst,  central  sarcoma,'  or  chronic  osteomyelitis. 

In  cases  of  delayed  union  or  non-union  with  inconclusive  clinical 
symptoms,  the  x-rays  are  diagnostic,  showing  the  presence  or  absence  of 
bony  callus  between  or  around  the  ends  of  the  fragments.  As  lime  salts 
are  practically  absent  in  fibrous  union,  there  will  be  no  shadow,  such  as 
that  cast  by  bone  in  the  process  formation.  Moreover,  the  skiagram 
will  often  show  the  cause  of  non-union. 

For  the  purpose  of  affording  protection  to  the  physician  who  first  sees 
a  case  of  injury  about  a  joint  which  may  be  associated  with  fracture 
of  the  bone,  a  skiagraphic  record  is  of  cardinal  importance,  since  subse- 
quent disability,  common  even  in  bone  injuries  properly  treated,  is  inevit- 
ably attributed  by  the  patient  to  negligence  on  the  part  of  his  physician. 
If  an  x-ray  picture  taken  during  this  period  of  continued  crippling  and, 
sometimes,  well-founded  discontent  exhibits  a  deformity  or  a  chronic 
arthritis  incident  to  an  unrecognized  fracture,  the  patient  will  probably 
find  twelve  of  his  peers  convinced  by  such  a  picture  of  his  right  to  redress. 
Nor  will  the  profession  at  large  consider  that  the  patient's  interests  have 
been  intelligently  conserved  by  the  doctor  who  has  failed  to  utilize  the 
only  means  by  which  an  accurate  diagnosis  can  be  made. 

As  to  the  method  of  examination,  whenever  possible  the  plate  should 
be  taken  from  at  least  two  directions,  the  exposures  being  at  right  angles 
to  each  other,  or  nearly  so.  A  single  good  picture  may  entirely  fail  to 
show  a  fracture  in  which  there  are  obvious  deformity  and  crepitus.  The 
regions  in  which  single  view  pictures  have  been  most  misleading  are  the 
elbow,  the  wrist,  the  knee,  and  the  ankle.  Oblique  fractures  of  the  long 
bones,  even  with  obvious  deformity,  occasionally  give  in  a  single  view 
picture  the  appearance  of  complete  continuity. 

In  some  regions  it  is  impossible  to  take  pictures  from  two  directions 
and  in  others  it  is  extremely  difficult.  The  region  of  the  shoulder  and 
upper  portion  of  the  humerus  can  be  skiagraphed  in  the  anteroposterior 
direction  only.  When  the  elbow  is  dressed  in  a  flexed  position,  the 
lateral  view  alone  is  possible.  The  pelvis  and  most  of  the  spine  cannot 
be  satisfactorily  examined  laterally.  The  upper  six  cervical  vertebrae 
can  be,  however,  and  the  picture  thus  afforded  is  usually  much  more 
satisfactory  than  the  anteroposterior  one.  Lateral  views  of  the  hips  and 
the  upper  portion  of  the  femoral  shaft  are  impossible. 

Both  anteroposterior  and  lateral  radiographs  are  important  in  demon- 


BONES  AND  JOINTS  39 

strating  fractures  of  the  humeral  condyles.  The  lateral  picture  best 
shows  injuries  of  the  olecranon  and  the  coronoid  process,  and  supra- 
condyloid  fractures.  The  side  view  is  the  essential  one  for  all  fractures 
of  the  patella,  os  calcis,  and  astragalus. 

It  should  be  a  general  rule  to  make  comparative  radiographs  of  the 
bones  and  joints  of  the  healthy  side  unless  the  diagnosis  is  obvious.  This 
is  especially  important  in  the  joint  lesions  of  young  people. 

The  direction  of  the  two  views  taken  should  be  as  nearly  as  possible 
in  the  same  plane  and  at  right  angles  to  each  other,  and  the  tube  should 
be  placed  as  nearly  as  possible  over  the  seat  of  injury.  If  the  source  of 
rays  be  unintentionally  or  carelessly  so  placed  as  to  throw  distorting 
shadows,  marked  deformity  may  appear  in  the  plate  when  it  does  not 
exist  in  fact. 

Epiphyseal  Separations. — These  injuries  will  not  show  in  the  skiagraph 
unless  there  be  associated  bone  lesion  or  pronounced  displacement. 
The  evidence  obtained  by  comparative  pictures  of  corresponding  portions 
of  the  opposite  side  is  often  at  least  suggestive.  Negative  results  in 
these  cases  are  not  conclusive. 

Fracture  of  the  ossified  epiphysis  or  extension  from  the  diaphysis 
into  the  epiphyseal  line,  with  or  without  epiphyseal  separation,  is,  how- 
ever, readily  shown. 

Inflammations. — Acute  suppurative  periosteitis,  osteomyelitis,  and 
epiphysitis  should  be  recognized  by  the  clinical  symptoms  and  receive 
proper  treatment  before  the  bone  changes  are  sufficiently  pronounced  to 
produce  a  characteristic  a^-ray  picture. 

Chronic  Osteomyehtis. — In  chronic  osteomyelitis  necrosed  bone  throws 
a  less  dense  shadow  than  the  surrounding  structure.  The  sequestrum, 
when  separated,  appears  as  a  loose  fragment  surrounded  by  a  clear  area 
representing  the  cavity  in  which  the  dead  bone  lies.  The  shadow  of  an 
involucrum  will  be  shown  as  soon  as  the  deposition  of  lime  salts  begins. 

In  pyogenic  osteomyelitis  chronic  from  the  start,  with  the  process 
comparatively  extensive,  the  shadow  of  the  affected  portion  of  the  bone, 
which  is  the  seat  of  a  rarefied  osteitis,  will  appear  decidedly  less  dense 
in  the  skiagraph  than  that  of  the  surrounding  osseous  structure  in  which 
both  condensation  and  thickening  are  likely  to  have  taken  place.  This 
condition  of  rarefied  osteitis  must  not  be  confused  with  the  appearance 
observed  in  the  cancellous  ends  of  bones  near  joints  exhibiting  lesions  of 
chronic  arthritis,  or  the  similar  appearance  developed  after  prolonged 
fixation  of  the  joint,  such,  for  instance,  as  is  needful  in  the  treatment 
of  fracture. 

In  the  type  of  chronic  osteomyelitis  characterized  by  local  abscess 
formation,  often  termed  Brodie's  abscess,  and  located  in  the  upper  ex- 
tremity of  the  tibia,  the  lesion  can  usually  be  readily  detected  and  accu- 
rately localized  by  means  of  a  radiograph  (Fig.  6) . 

Tuberculosis. — Tuberculosis  can  be  detected  as  soon  as  bone  disinte- 
gration has  progressed  far  enough  to  cause  an  appreciable  difference  in 
the  density  of  the  shadow  of  the  affected  portion.  Hence,  as  the  process 
of  caseation  and  softening  is  essentially  slow,  the  diagnosis  as  to  the  seat 


40      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

of  disease  and  its  extent  can  be  made  by  the  x-ray  before  softening  has 
taken  place,  and  at  the  time  when  cHnical  diagnosis  is  more  or  less 
uncertain. 

The  accm'ate  localization  of  the  seat  of  invasion  is  of  cardinal  impor- 
tance from  the  standpoint  of  treatment.  In  tuberculous  disease  involving 
the  carpus  and  tarsus,  the  skiagraph  will  show  whether  it  is  distinctly 
limited  to  one  of  the  small  bones,  as  an  osteitis,  or  to  the  joint  structure, 
as  an  arthritis;  or  whether  the  disease  is  more  widespread. 

In  the  late  stages  of  tuberculous  infiltration  characterized  by  exten- 
sive osteomyelitis,  with  necrosis,  the  a;-ray  picture,  while  showing  the 
lesion,  in  no  way  indicates  its  tuberculous  nature. 

Fig.  6 


Superficial  "Brodie's  abscess"  head  of  tibia  of  male,  aged  twenty  years, 
indicates  exact  location  of  lesion. 


Radiograph 


Syphilis. — In  addition  to  the  demonstration  of  the  seat,  nature,  and 
extent  of  the  syphilitic  bone  invasion,  the  skiagraph  has  a  distinct  diag- 
nostic value  in  that  it  may  identify  the  lesion  as  one  of  syphilis,  and, 
moreover,  may  picture  the  traces  of  former  lesions  of  a  similar  nature. 

There  are  two  distinctly  different  appearances  found  in  the  skiagraphs 
of  bone  lesions  of  acquired  syphilis,  dependent  upon  whether  the  process 
is  essentially  one  of  destruction  or  of  proliferation. 

In  the  typically  active  lesion,  the  periosteal  gumma,  there  will  be  shown 
a  shadow  of  the  swollen  periosteum  and  usually  of  the  soft  parts  as  well. 
Later,  the  evidence  of  osseous  degeneration  is  afforded  by  a  roughened 
surface  indicating  a  superficial  caries  or  a  deeper  or  more  extensive  area 


BONES  AND  JOINTS 


41 


of  distinctly  rarefied  or  even  necrosed  bone.  Necrosis  is  unusual,  since 
one  of  the  most  characteristic  features  of  syphilis  is  that  a  large  portion 
or  even  the  entire  shaft  of  the  long  bone  may  become  extremely  rarefied 
without  actual  necrosis  taking  place. 

As  in  all  other  chronic  bone  inflammations,  there  is  an  accompanying 
condensation  of  the  surrounding  structure,  the  shadow  of  the  bone 
immediately  around  the  localized  lesion  appearing  denser  than  normal 
in  the  later  stages  of  the  affection.  This  proliferative  processes  especially 
evident  on  the  surface  (Fig.  7),  and  the  subperiosteal  new  bone  forma- 
tion will  be  observed  in  the  form  of  nodes  and  osteophytes  in  the  case  of 
localized  lesions,  or  of  a  considerable  general  thickening  if  the  process  be 
extensive. 

Fig.  7 


Syphilitic  osteomyelitis  involving  nearly  entire  shaft  of  ulna  in  a  girl,  aged  sixteen  years. 
Note  coincident  rarefying  osteitis  and  subperiosteal  newgrowth. 

The  distinction  between  chronic  syphilitic  osteomyelitis  and  that 
due  to  other  infecting  agents  is  based  mainly  on  the  extensive  rarefac- 
tion and  the  superficial  thickening  without  necrosis. 

Bone  sarcoma  in  its  usual  form  resembles  syphilis  only  in  its  earliest 
stage.  The  less  malignant  and  less  common  type  of  sarcoma,  associated 
with  more  or  less  new  bone  formation,  may  sometimes  lead  to  error, 
though  the  bone  formation  produces  an  appearance  quite  unlike  that 
characteristic  of  syphilis.  Periosteal  sarcomas  are  more  likely  to  lead 
to  mistake  from  the  x-ra.j  standpoint,  since  the  appearances  they  present 
are  not  uniformly  so  typical  as  those  shown  by  the  central  growths. 


42      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

Osteitis  deformans,  which  may  present  a  picture  closely  resembling 
that  of  syphilis,  is  rarely  accompanied  by  the  superficial  localized  bony 
outgrowths  observed  in  the  latter  disease. 

Post-typhoidal  osteitis  may  resemble  the  early  stage  of  gumma,  but 
the  raised  periosteum  is  but  little  thickened,  nor  is  the  surrounding  osseous 
structure  markedly  condensed. 

In  hereditary  syphilis  the  skiagram  is  less  characteristic.  Usually  the 
seat  of  the  osseous  lesions  aside  from  dactylitis  is  at  the  epiphyseal  junc- 
tion with  the  bone  shaft,  a  locality  in  which  an  rc-ray  examination  is 
unsatisfactory  during  infancy.  Serration,  irregularity,  and  broadening 
of  the  diaphysis  where  it  joins  the  cartilage,  or  enlargement  of  its  entire 
extremity,  accompanied  by  sclerosis  and  condensation,  may  be  shown. 
A  similar  appearance  may  be  seen  in  rickets,  but  here  the  widening 
is  closely  limited  to  the  extreme  end  of  the  diaphysis  and  is  not  accom- 
panied by  sclerosis  or  serration. 

In  syphilitic  dactylitis  the  diaphysis  is  greatly  thickened  throughout, 
or  there  is  more  or  less  widespread  necrosis,  with  perhaps  a  tendency  to 
the  formation  of  an  enveloping  involucrum. 

Miscellaneous  Pathological  Conditions  Peculiar  to  Bones. — 
Osteitis  Deformans. — The  characteristic  skiagraphic  features  of  this 
condition  are  the  uniform  enlargement  of  a  large  portion  or  the  entire 
shaft  of  the  affected  long  bone  or  bones,  accompanied  by  a  marked 
condensation  or  sclerosis  of  the  compact  structure.  At  first  the  thick- 
ening is  especially  noticeable  as  involving  the  compact  portion,  and 
it  may  encroach  upon  the  medullary  canal.  The  latter,  however,  is 
usually  rendered  more  perceptible  through  contrast  with  the  extreme 
density  of  the  compact  structure.  The  medullary  cavity  obviously 
shares  in  the  enlargement  in  some  instances.  Occasionally,  when  the 
bones  have  assumed  tremendous  proportions,  in  late  stages  of  the  disease, 
the  central  cavity  has  undergone  an  extreme  degree  of  hypertrophy, 
even  surpassing  that  of  the  compact  structure,  accompanied  by  enormous 
thickening  of  the  normally  thin  walls.  This  process  involves  the  can- 
cellous ends  as  well,  and  the  correspondingly  enlarged  medullary  spaces 
give  to  the  entire  bone  somewhat  of  a  multilocular  cystic  appearance. 
At  almost  any  stage  of  the  disease  the  skiagraphic  appearance  is  usually 
sufficiently  characteristic  for  diagnosis  of  the  condition. 

Acromegaly. — The  skiagraphic  picture  of  the  bones  in  this  condition 
shows  nothing  but  uniform  hypertrophy. 

Achondroplasia. — The  skiagraph  shows  the  typical  appearance  of  the 
long  bones — the  abnormally  short  and  slender  diaphyses  or  shafts  and 
the  relatively  large  epiphyses  or  ends,  which  are,  however,  actually  nor- 
mal or  nearly  so  in  size  and  development,  while  the  shafts  are  deficient. 

Fragilitas  Ossium. — ^The  most  noticeable  skiagraphic  feature  in  this 
condition  is  the  extremely  rarefied  appearance  of  the  long  bones,  especially 
at  their  extremities,  arising  from  the  imperfect  ossification  of  the  bone 
trabeculse  characteristic  of  the  disease.  The  extreme  rarefaction  extends 
into  the  shafts  far  beyond  the  normal  limits,  showing  the  reason  for  the 
frequency  of  fractures. 


BONES  AND  JOINTS 


43 


Rickets. — The  skiagraph  has  httle  value  in  the  examination  of  the  bones 
during  the  active  stage  of  this  disease. 

In  connection  with  tlie  deformities  arising  from  the  disease,  especially 
from  the  standpoint  of  the  surgeon,  the  skiagraph  is  of  great  value,  since 
the  exact  seat  and  extent  of  deformity  can  then  be  determined.  After 
the  application  of  the  retentive  dressing  it  is  an  easy  means  of  deter- 
mining whether  the  proper  relations  have  been  preserved.  The  nature 
and  extent  of  rachitic  deformities  of  the  pelvis  in  pregnant  women  can 
readily  be  demonstrated  by  the  a;-rays. 

Fig.  S 


Osteosarcoma  of  shaft  of  tibia  in  male,  aged  twenty-five  years. 

of  previous  osteoma. 


Sarcomatous  degeneration 


Tumors  of  Bone. — The  appearance  of  each  of  the  more  common 
tumors  is  sufficiently  characteristic  to  make  the  x-ray  examination  a 
fairly  reliable  means  of  determining  the  exact  nature  and  the  origin  and 
seat  of  the  growth. 

Sarcoma. — In  the  periosteal  form  the  skiagraphic  appearance  is  not 
so  distinctly  characteristic  as  in  the  central  variety.  If  the  diagnosis  of 
sarcoma  is  fairly  well  assured,  the  skiagraph  will  easily  determine  which 
of  these  two  varieties  is  present  (Fig.  8). 


44      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

In  the  early  stage  of  a  periosteal  growth  its  shadow  will  probably  be 
in  evidence,  but  there  is  nothing  t^^ical  in  the  slight  bony  destruction 
accompanying  the  round-cell  type,  and  the  appearance  may  be  more 
or  less  confusing.  The  skiagraph  cannot  always  be  accurately  inter- 
preted by  itself,  but  must  be  studied  in  connection  with  the  clinical  data. 

In  the  semimalignant  types  of  osteosarcoma  the  appearance  is  usually 
characterized  by  the  evidence  of  new  bone  formation,  together  with  more 
or  less  bony  destruction.  There  is  considerable  variation  to  be  noted 
in  the  appearances  in  different  cases,  and,  although  they  are  usually 
characteristic,  some  experience  is  required  to  interpret  correctly  the 
skiagraphs  of  these  less  common  growths  (Fig.  9). 

Fig.  9 


Osteosarcoma — semimalignant  or  giant-cell  type — of  calcis  of  female,  aged  forty-seven  years. 
Note  new  bone  formation  in  contrast  with  complete  bone  destruction  shown  in  more  malignant 
form  (Fig.  10). 

In  the  malignant  round-cell  central  osteosarcomata  the  appearance 
is  invariably  characteristic,  except  in  the  early  stages  of  the  growth, 
when  it  may  be  confused  with  a  bone  cyst  or  a  syphilitic  osteitis.  After 
the  growth  has  reached  an  appreciable  size,  however,  the  appearance 
of  this  type  cannot  readily  be  mistaken  (Fig.  10). 

Bone  Cysts. — The  skiagraphic  appearance  of  this  condition  closely 
resembles  that  of  central  sarcoma.  Although  there  are  some  points  of 
distinction,  the  diagnosis  by  the  a;-ray  examination  alone  is  difficult 


BONES  AND  JOINTS 


45 


and  sometimes  impossible.  A  knowledge  of  the  clinical  history  of  the 
case  is  very  important  in  interpreting  the  skiagraph.  Bone  cysts  are 
comparatively  rare,  however. 

Osteoma. — The  skiagraph  readily  establishes  the  nature  of  these 
tumors,  together  with  their  size,  location,  and  anatomical  relations, 
especially  in  connection  with  neighboring  joints.  There  is  a  type  of 
osteoma  which  bears  some  resemblance  to  sarcoma,  and  through  lack 
of  experience  it  may  be  mistaken  for  the  latter  (Fig.  11). 


Fig.  10 


Typical  osteosarcoma  of  lower  end  of  radius  in  adult  female. 


Enchondroma. — The  shadow  is  faint  and  lacks  any  characteristic 
details,  owing  to  the  homogeneous  structure  of  the  growth  and  the 
slight  difference  in  density  between  it  and  the  surrounding  soft  struc- 
tures. The  x-ray  diagnosis  is  usually  more  one  by  exclusion  than  a 
direct  one. 

Carcinoma. — In  this  condition  the  value  of  the  skiagraph  depends  to  a 
great  extent  upon  whether  the  bone  is  involved  by  contiguity  or  by  metas- 
tasis. In  the  former  instance  the  examination  will  show,  first,  whether 
the  bone  is  involved  or  not,  and  secondly,  the  extent  of  involvement. 
Metastatic  carcinoma  of  bone  has  no  special  skiagraphic  feature  of  its 


46      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

own,  and  the  diagnosis  must  usually  be  made  with  the  assistance  of  the 
clinical  data. 

Injuries  and  Surgical  Affections  of  the  Joints. — Dislocations. — The 
diagnosis  of  the  majority  of  dislocations,  especially  those  of  the  larger 
joints,  can  be  made  without  the  assistance  of  the  skiagraph,  but  that  it 
is  not  always  done  is  shown  by  the  comparatively  large  number  of  old 
unrecognized  unreduced  dislocations  seen  by  the  x-ra,j  specialist.  The 
radiograph  will  show  the  displacement  and  will  prove  the  completeness 

Fig.  11 


Osteoma  of  humerus  in  a  female,  aged  thirteen  years.      Appearance  not  unlike  that  of 
sarcoma  in  some  respects. 


or  incompleteness  of  reduction,  but  its  main  value  lies  in  the  detection 
of  complicating  fractures.  All  luxations  should  be  so  examined  whether 
satisfactory  reduction  has  been  accomplished  or  not. 

Such  fractures  are  apt  to  extend  into  the  joint,  and  they  may  be  over- 
looked because  of  the  greater  prominence  of  the  manifestations  of  the 
dislocation,  or  because  they  are  obscured  by  swelling,  or  because  they  are 
of  such  types  as  are  naturally  difficult  to  diagnosticate  clinically.  Their 
detection  is  important  and  a  routine  x-raj  examination  of  all  cases  of 


BONES  AND  JOINTS  47 

dislocation,  either  before  or  after  reduction,  is  the  most  rehable  means 
of  avoiding  otherwise  inexcusable  mistakes  which  are  Hkely  to  result  in 
disability  and  discomfort  to  the  patient  and  to  reflect  discredit  upon  the 
one  who  treats  him. 

In  children  dislocations  are  sometimes  mistaken  for  epiphyseal  separa- 
tions, and  vice  versa,  but  the  skiagraph  will  nearly  always  reveal  the 
exact  condition  which  exists,  although  extreme  care  in  taking  the  picture 
and  a  certain  amount  of  experience  are  often  essential  for  correct  inter- 
pretation of  the  plates. 

The  common  dislocations  of  the  shoulder-joint  are  rarely  difficult  to 
diagnosticate  clinically,  although  old  unreduced  ones  are  frequently  met 
with.  It  should  be  borne  in  mind,  however,  that  they  are  often  compli- 
cated by  fractures,  usually  of  the  surgical  neck  of  the  humerus,  rarely 
of  the  anatomical  neck,  or  other  less  common  fractures.  In  children  this 
dislocation  may  be  associated  with  separation  of  the  upper  epiphysis  of 
the  humerus.  An  x-ray  examination  of  a  shoulder  is  advisable  after 
reduction,  because  in  some  instances  reduction  is  found  to  be  incomplete 
even  when  it  has  apparently  been  satisfactorily  performed.  The  com- 
paratively rare  subspinous  dislocation  is  rather  difficult  to  demonstrate 
with  absolute  certainty  in  the  skiagraph.  These  same  remarks  are 
applicable  in  connection  with  acromioclavicular  dislocations,  although 
the  latter  are  usually  less  difficult  to  detect. 

Fractures  of  either  the  clavicle  or  the  acromion  in  close  proximity  to 
this  joint  are  sometimes  very  difficult  to  distinguish  from  dislocations 
except  by  means  of  the  skiagraph. 

By  far  the  greatest  number  of  serious  mistakes  in  diagnosis  of  disloca- 
tions are  made  in  connection  with  those  at  the  elbow-joint,  either  in  failure 
to  detect  the  presence  of  this  injury  or  of  one  or  more  complicating  frac- 
tures, or  both.  The  skiagraph  shows  that  dislocations  at  this  joint  are 
complicated  by  fractures  in  a  large  percentage  of  cases. 

A  careful  skiagraphic  study  of  injuries  of  the  wrist  shows  that  disloca- 
tions of  the  carpal  bones  are  far  more  common  than  was  formerly  supposed. 
Luxations  of  one  or  more  of  these  bones  may  occur  independently,  but 
they  are  usually  associated  with  fractures  of  the  bones  of  the  forearm, 
which,  by  the  greater  prominence  of  their  manifestations,  are  apt  to  divert 
attention  from  the  possibility  or  even  the  evidence  of  the  former  injury. 
Some  of  these  fracture-dislocations  of  the  wrist  are  complicated.  Blows 
on  the  wrist  by  automobile  cranks  have  become  a  frequent  cause  of 
such  injuries. 

Carpal  dislocations  are  difficult  to  diagnosticate  clinically,  and,  even  in 
the  skiagraph,  a  dislocation  of  one  or  more  of  the  bones  may  be  over- 
looked unless  pictures  of  the  opposite  wrist  are  made  for  comparison. 

Traumatic  dislocations  of  the  hip  do  not  usually  require  a;-ray  examina- 
tion for  their  detection,  but  there  is  always  the  possibility  of  compli- 
cating fractures  in  these  cases,  especially  of  the  rim  of  the  acetabulum. 
In  connection  with  congenital  hip  dislocations,  the  skiagraph  is  important 
as  a  means  of  diagnosis  alone;  it  is  also  of  great  value  in  determining  the 
extent  of  development  of  the  acetabulum  and  the  head  and  neck  of  the 


48      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

femur,  and,  in  this  way,  of  showing  to  a  certain  extent  the  possibihties 
of  obtaining  a  successful  result  in  treatment.    It  may  also  offer  some  sug 
gestions  as  to  the  best  method  of  treatment  (Figs.  12  and  13). 

Fig.  12 


Congenital  dislocation  of  left  hip  in  a  boy,  aged  seven  years.      Note  lack  of  development 
of  acetabulum  and  head,  and  formation  of  new  socket. 


Fig.  13 


Congenital  dislocation  of  left  hip  in  a  child,  aged  two  years.      Note  lack  of  development 

of  acetabulum. 


BONES  AND  JOINTS   '  49 

The  x-raj  examination  has  now  come  to  play  an  essential  part  in  the 
treatment  of  these  cases.  It  is  the  only  accurate  means  of  determining 
the  measure  of  success  in  reduction  and  the  relation  of  the  head  of  the 
femur  with  the  acetabulum  after  the  application  of  the  retentive  dressings, 
especially  as  the  latter  are  employed  in  connection  with  the  after-treat- 
ment of  the  "bloodless"  methods  of  reduction.  The  examinations  can 
usually  be  made  through  the  casts  if  the  removal  of  the  latter  is  not 
desirable. 

Dislocations  of  the  tarsus  are  not  so  frequent  as  are  those  of  the  wrist 
and  carpus,  but  their  detection  by  manual  examination  may  be  equally 
difficult,  and  the  nature  of  the  injury  may  not  be  readily  or  accurately 
determined  without  the  assistance  of  the  skiagraph.  Subluxations  in 
which  a  comparatively  slight  amount  o£  displacement  is  permitted  by 
the  torn  or  stretched  interosseous  ligaments  are  of  somewhat  frequent 
occurrence,  as  is  shown  by  the  skiagraph,  but  their  detection  by  other 
means  is  usually  difficult  or  impossible. 

Arthritis. — A  discussion  of  the  value  of  a;-ray  diagnosis  in  connection 
with  the  various  forms  of  joint  inflammation  renders  it  necessary  to 
follow  some  appropriate  classification  of  the  different  types  of  arthritis, 
in  the  light  of  our  more  recent  knowledge  concerning  certain  distinguish- 
ing features  to  be  observed  in  the  radiographic  appearance  characteristic 
of  each  one.  The  classification  here  employed  does  not  differ  materially 
from  the  one  which  is  now  coming  into  use  by  many  authorities,  and  is  as 
follows : 

1.  Acute  arthritis: 

(a)  Septic. 

(6)  Infectious,  acute  suppurative  type. 

(c)  Acute  articular  rheumatism. 

2.  Chronic  tuberculous  arthritis. 

3.  Chronic  non-tuberculous  arthritis: 

(a)  Atrophic  type. 
(6)  Hypertrophic  type. 

(c)  Infectious  type. 

(d)  Gouty  arthritis. 

4.  Arthropathies. 

1.  Acute  Arthritis.  In  either  the  septic,  infectious,  or  rheumatic  form 
the  skiagram  is  of  little  or  no  diagnostic  value  in  the  early  stage  before 
the  destructive  process  has  advanced  to  any  appreciable  extent.  The 
diagnosis  by  other  means  is,  however,  usually  obvious.  At  a  later 
stage,  after  erosion  of  the  articular  surfaces  or  more  extensive  destruction 
of  bone  has  taken  place,  the  skiagraph  can  be  relied  upon  to  indicate 
such  changes,  and  also  their  extent  and  exact  locality. 

2.  Chronic  Tuberculous  Arthritis.  This  being  a  slow  and  at  the  same 
time  progressively  destructive  process  makes  it  possible  to  detect  the 
existence  of  the  disease  and  to  determine  the  locality  of  the  focus  at  a 
relatively  early  stage. 

All  of  the  chronic  forms  of  arthritis  present  more  or  less  characteristic 
skiagraphic  appearances,  but  the  a;-ray  diagnosis  is  particularly  important 
4 


50      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

in  this  form,  because  it  is  invariably  reliable  and  will  show  the  presence  of 
the  disease  at  an  early  period,  often  before  the  clinical  diagnosis  can  be 
settled  with  certainty.  A  negative  x-rsij  diagnosis  should  not  be  accepted 
as  final  in  the  incipient  stages  of  the  affection.  As  soon  as  the  process 
has  involved  the  bony  structure  to  any  appreciable  extent,  the  resulting 
erosion  of  the  articular  surfaces  in  a  case  of  primary  arthritis  is  easily 
demonstrable.  The  primary  focus  of  the  disease  lies  often  in  an  adja- 
cent epiphysis  or  just  beyond  the  epiphyseal  line.  The  location  of  such 
a  focus  can  be  made  with  certainty  only  by  the  a;-rays  (Figs.  14  and  15). 
In  hip-joint  disease  the  diagnosis  can  be  made  by  means  of  the  skia- 
graph at  a  comparatively  early  period.  In  advanced  cases  a:;-ray  findings 
serve  as  useful  guides  in  determining  the  form  and  extent  of  surgical 
intervention.  , 

Fig.  14 


Tuberculous  abscess  of  lower  end  of  diapliysis  of  radius  in  a  child,  aged  six  years. 
Radiograph  indicates  exact  location  and  extent  of  lesion. 

3.  Chronic  Non-tuherculous  Arthritis. — Atrophic  Type. — This  type  is 
characterized  by  slow  progress  with  subacute  exacerbations,  and,  observed 
in  ill-nourished  adults  of  low  vitality.  It  usually  affects  first  the  joints 
of  the  hands  and  wrists.  The  radiographic  features  of  this  type  are: 
(a)  Absorption  and  erosion  of  the  articular  cartilages,  represented  in 
the  skiagraph  by  an  abnormally  close  approximation  of  the  articular, 
surfaces  of  the  bones;  (b)  erosion  of  the  articular  surfaces  of  the  bones, 
readily  demonstrable  radiographically;  and  (c)  rarefaction  of  the  can- 
cellous structure,  which  is  in  a  measure  a  part  of  the  atrophic  process 
and  partly  an  atrophy  of  disuse. 

Hypertrophic  Type. — This  type  is  observed  most  frequently  in  later 
adult  life,  usually  in  active  individuals  who  are  apparently  otherwise 
healthy  and  well  nourished.  The  course  of  the  disease  is  usually  more 
gradual;  exacerbations  may  be  observed,  but  are  usually  slight  or  wanting. 
The  joints  of  the  hands  and  wrists  are  first  affected,  the  term  "Heberden's 
nodes"  being  applied  to  the  swellings  due  to  the  hypertrophies,  but  the 
disease  is  manifest  in  the  larger  joints  quite  as  frequently,  particularly 


BONES  AND  JOINTS 


51 


the  knees  and  hips.  It  is  frequently  monarticular  clinically,  especially 
in  the  case  of  the  large  joints,  but  skiagraphic  evidence  of  the  disease 
is  very  often  found  on  the  opposite  and  apparently  healthy  side.  The 
radiographic  features  of  this  type  are:  (a)  Absorption  and  erosion  of 
the  articular  cartilages;  (b)  characteristic  hypertrophy  of  the  bones  near 
the  articular  surfaces ;  and  (c)  more  or  less  condensation  of  the  cancellous 


Fig.  15 


Tuberculous  osteomyelitis  and  epiphysitis  of  lower  ends  of  tibia  and  fibula  of  a  child,  aged 
four  years.      Radiograph  indicates  exact  location  and  extent  of  process. 

structure,  although  rarefaction  is  apt  to  predominate  as  a  part  of  the 
coincident  atrophy  of  disuse. 

The  typical  picture  is  not  always  found  in  these  cases,  as  the  process 
of  atrophy  often  accompanies  that  of  hypertrophy.  Evidences  of  absorp- 
tion and  erosion  of  cartilage  are  more  apt  to  be  observed  than  of  hyper- 
trophy, and  erosion  of  the  articular  surfaces  of  the  bones  is  often  found 
associated  with  the  excessive  deposits  outside. 


52      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

Infectious  Type. — Broadly  speaking,  this  type  includes  all  chronic 
non-tuberculous  joint  manifestations  not  conforming  to  either  of  the  two 
preceding  types,  and  not  of  gouty  origin.  From  the  etiological  point  of 
view,  the  term  applies  to  all  chronic  joint  manifestations  associated  as 
complications  or  sequelae  with  gonorrhea,  pneumonia,  many  of  the  acute 
infectious  fevers,  and  such  joint  disturbances  as  are  referable  to  various 
toxemias  arising  from  altered  metabolism  and  other  sources.  The  joint 
condition  into  which  acute  articular  rheumatism  lapses  often  conforms 
to  this  type. 

Fig.  16 


Case  of  supposed  metatarsalgia  in  adult  female.      Note  exostosis  on  second  metatarsal, 
causing  pain  by  nerve  pressure. 

The  process  in  some  of  these  joint  complications  may  be  acute  and 
go  on  rapidly  to  suppuration,  but  this  is  the  exception.  The  great 
majority  of  these  manifestations  are  essentially  of  a  chronic  nature,  and 
the  prominent  clinical  features  are  more  or  less  pain,  tenderness,  and 
disability,  associated  with  articular  and  periarticular  swelling,  and  per- 
haps atrophy  due  to  disuse. 

The  radiographic  features  of  this  type  are:  (a)  The  entire  absence  of 
hypertrophy  of  the  ends  of  the  bones  and  of  atrophy  of  their  articular 
surfaces;  (6)  often  more  or  less  absorption  of  the  articular  cartilages, 
shown  in  the  skiagraph  by  the  closer  approximation  of  the  bones,  but  not 
usually  an  erosion;  (c)  evidences  very  often  of  articular  swelling  due  to 
effusion,  and  of  periarticular  swelling  made  evident  by  thickening  of 
the  capsule  and  other  periarticular  structures;  and  (d)  a  rarefaction 
of  the  cancellous  structure,  corresponding,  in  part  at  least,  to  a  local 
atrophy  of  disuse. 


BONES  AND  JOINTS 


53 


It  will  be  noted  that  the  essential  difference  between  this  type  and  the 
two  preceding  ones  is  the  absence  of  any  distinct  articular  lesions. 

Gouty  Arthritis. — The  characteristic  joint  manifestations  of  gout  as 
revealed  in  the  skiagraph  make  this  form  of  arthritis  a  distinct  type  in 
itself.  The  special  radiographic  features  are  the  early  destruction  of 
bone  and  the  actual  disappearance  of  the  cancellous  trabeculse  of  the 
ends.  The  process  may  involve  the  shafts  of  the  short  long  bones  as  well. 
The  appearance  often  somewhat  resembles  that  of  central  osteosarcoma. 
Evidence  is  also  to  be  found,  of  course,  of  erosion  of  the  articular  sur- 
faces. The  tophi  are  to  be  included  in  the  periarticular  swellings,  but 
they  do  not  cast  characteristic  shadows. 


Fig.  17 


Spur  on  vmder  surface  of  os  calcis  in  female,  aged  sixty  years.      Radiograph  made  for  suspected 
piece  of  needle,  but  shows  spur  to  berths  cause  of  pain. 


4.  Arthropathies. — ^These  present  skiagraphic  findings  in  accordance 
with  the  nature  and  cause  of  the  pathological  process.  There  is  nothing 
distinctive  in  the  appearance  of  the  joint  manifestations  of  underlying 
nerve  lesions. 

Loose  Bodies. — ^The  presence  of  loose  bodies  in  joints  can  be  detected 
by  means  of  the  radiograph,  provided  their  structure  is  of  sufficient 
density  to  cast  perceptible  shadows. 

The  knee  is  the  joint  involved  in  the  great  majority  of  instances,  and 
a  detached  or  movable  semilunar  cartilage  is  the  offending  body  in  per- 
haps the  majority  of  cases.  The  skiagraph  is  of  value  only  in  so  far 
as  it  excludes  other  conditions. 

The  presence  of  small  detached  fragments  of  bone,  calcified  synovial 


54      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

fringes  with  or  without  attachment  by  a  pedicle,  and  sometimes  even  rice 
bodies,  can  be  satisfactorily  demonstrated. 

Bunion. — ^The  x-rays  are  at  times  useful  in  showing  the  presence  of  de- 
structive inflammatory  processes  in  the  bones  or  the  joint.  They  are  also 
helpful  in  suggesting  a  form  of  surgical  intervention  when  this  is  needful. 

Orthopedic  Conditions. — Orthopedic  conditions,  especially  cervical  rib, 
congenital  dislocations  of  the  hip,  coxa  vara,  scoliosis,  genu  varum  and 
valgum,  and  congenital  malformations  and  deficiencies,  present  a  wide 
field  for  a;-ray  diagnosis,  and  in  many  instances  it  is  essential  in  deter- 
mining the  exact  nature,  seat,  and  extent  of  the  condition. 


INJURIES  AND  SURGICAL  AFFECTIONS  OF  THE  HEAD. 

Foreign  Bodies. — The  examination  for  foreign  bodies  in  the  head 
requires  special  mention  because  of  the  serious  disturbances  they  may 
provoke,  the  necessity  of  their  removal  in  so  many  instances,  the  compara- 
tive frequency  of  gunshot  injuries  in  this  part  of  the  body,  and  the  im- 
portance of  accurate  localization  by  means  of  special  apparatus  requiring 
special  methods.  In  the  large  majority  of  cases  it  is  necessary  to  deter- 
mine the  exact  location  of  bullets,  whether  lodged  within  or  outside  of 
the  cranial  cavity,  first,  in  order  to  determine  the  advisability  of  extrac- 
tion or  whether  the  body  is  accessible  or  not;  secondly,  accurate  locali- 
zation simplifies  the  operation  for  removal  by  indicating  the  easiest  and 
safest  avenue  of  approach.  Such  special  methods  should  always  be 
employed  if  accuracy  is  desirable,  as  the  crude  method  of  localization 
by  making  two  pictures  in  opposite  directions  is  not  suflficiently  reliable, 
and  in  fact  may  be  very  misleading. 

In  the  eye  and  orbit  foreign  bodies  may  be  localized  with  unusual 
accuracy,  and  an  examination  is  practically  imperative  in  most  instances. 
There  are  a  few  important  sources  of  error  to  be  avoided,  but  such 
examinations  must  be  made  with  care  and  by  competent  persons.  The 
detection  of  a  foreign  body  in  the  orbit  depends  upon  the  density  of  the 
substance.  Small  fragments  of  superior  qualities  of  glass,  as  from  the 
lenses  of  spectacles,  splinters  of  wood,  and  other  less  dense  substances, 
may  not  cast  shadows,  and  their  presence,  therefore,  may  not  be  detected. 
Hence,  negative  x-ray  diagnosis  in  such  instances  is  not  always  conclusive. 

The  Nose  and  Accessory  Sinuses. — It  is  possible  to  secure  excellent 
details  of  the  accessory  sinuses,  especially  by  means  of  the  stereoscopic 
method.  Important  data  may  be  derived  from  the  x-ray  examination 
of  the  frontal  sinuses — their  size,  shape,  the  extent  of  their  development, 
the  number  of  subdivisions  or  the  septa  dividing  them,  and  whether 
they  are  symmetrical  on  both  sides.  In  addition,  the  presence  of  pus  and 
even  any  considerable  degree  of  thickening  of  the  lining  mucous  mem- 
brane can  be  determined  with  uniform  accuracy.  The  radiograph  is, 
therefore,  a  valuable  means  of  diagnosis  of  disease  of  these  cavities  and 
is  far  superior  to  transillumination.  The  skiagraph  is  equally  reliable 
and  useful  for  the  detection  of  disease  and  newgrowths  of  the  antra. 


INJURIES  AND  SURGICAL  AFFECTIONS  OF  THE  HEAD        55 

Although  it  has  always  been  possible  to  radiograph  the  frontal  and 
ethmoidal  sinuses  and  the  antra  laterally,  it  is  only  since  anteroposterior 
and  stereoscopic  views  have  become  practicable  that  we  have  been  able 
to  obtain  uniformly  reliable  and  useful  data.  The  anterior  ethmoid 
sinuses  may  be  examined  in  the  fore-and-aft  direction,  but  the  stereo- 
scopic method  shows  them  to  much  better  advantage.  The  sphenoid 
and  posterior  ethmoid  sinuses  can  be  clearly  shown  stereoscopically,  but 
they  cannot  be  satisfactorily  examined  otherwise. 

Disease  (caries  and  necrosis)  of  the  bony  walls  of  all  of  these  cavities 
can  be  detected  with  reasonable  accuracy,  as  can  also  the  presence  and 
the  extent  of  newgrowths. 

Tumors. — ^Tumors  involving  the  bones  of  the  skull  are  mainly  recog- 
nizable by  the  presence  of  either  destruction  or  formation  of  bone.  Osteo- 
mata  may  usually  be  detected  by  the  application  of  proper  methods  of 
examination.  Destructive  tumors,  such  as  sarcomata  involving  the 
cranial  vault  or  base  of  the  skull,  may  also  be  detected  and  studied 
under  favorable  conditions. 

When  tumors  involve  the  lower  jaw  the  skiagraphic  evidence  is  posi- 
tive and  reliable. 

In  connection  with  brain  tumors,  recent  advances,  especially  in  the 
stereoscopic  method,  have  made  it  possible  to  obtain  valuable  informa- 
tion in  some  instances,  although  the  a;-rays  are  not  often  dependable  for 
diagnosis. 

Dental  Radiography. — Many  of  the  abnormalities  and  pathological 
conditions  in  connection  with  the  teeth  and  surrounding  structures 
that  were  formerly  exceedingly  difficult  or  even  impossible  to  determine 
with  certainty  are  now  clearly  and  accurately  demonstrated  by  the 
skiagraph.  Some  of  these  conditions  can  be  determined  in  no  other 
way.  Among  them  may  be  mentioned  the  presence  of  unerupted  and 
impacted  teeth,  supernumerary  unerupted  teeth,  absence  of  teeth  not 
erupted,  deformities  and  exostoses  of  roots  causing  symptoms  or  complica- 
ting extraction,  abnormal  relations  of  any  of  the  upper  set  with  the  antra, 
presence  of  foreign  bodies,  such  as  broken  pieces  of  instruments  in  the 
root  canals  or  beyond  the  apices,  fillings  in  the  root  canals,  and  calcifi- 
cation of  the  pulp  or  "pulp  stones."  The  skiagraph  is  the  only  certain 
means  of  diagnosticating  dentigerous  cysts. 

The  x-raj  examination  is  of  considerable  value  in  the  diagnosis  of 
diseases  of  the  surrounding  structures,  such  as  alveolar  abscess  and 
necrosis  and  pericementitis,  and  is  often  useful  in  showing  the  relations 
of  the  roots  in  cases  in  which  irregularities  of  the  teeth  exist  and  in  which 
correction  is  indicated.  It  is  also  important  in  showing  the  relations 
of  teeth  to  fractures,  especially  of  the  lower  jaw. 

Salivary  Calculus. — -The  detection  of  calculi  in  the  duct  of  the  parotid 
gland  is  not  difficult,  but  Wharton's  duct  is  overshadowed  by  the  lower 
jaw,  and  shadows  of  calculi  in  this  duct  are  rather  difficult  to  differentiate, 
although  the  a:-ray  diagnosis  can  be  made. 


56      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

INJURIES  AND  SURGICAL  AFFECTIONS  OF  THE  THORAX  AND 
THORACIC  VISCERA. 

In  the  examination  of  the  chest,  the  x-rays  have  a  wider  appHcation 
in  connection  with  the  diagnosis  of  medical  than  of  surgical  conditions. 
This  is  largely  because  the  number  of  injuries  involving  this  part  of  the 
body  is  relatively  small  and  the  majority  of  disease  conditions  affecting 
the  thoracic  organs  are  distinctly  medical  in  respect  to  their  treatment. 

The  Ribs. — Fractures. — X-ray  examinations  are  made  less  frequently 
for  fractures  of  the  ribs,  perhaps,  than  for  fractures  of  any  other  bones 
of  the  body  except  those  of  the  skull.  There  is  no  particular  reason  why 
the  skiagraph  should  not  be  more  often  employed  in  this  connection, 
but  the  failure  to  use  this  method  more  extensively  probably  arises  from 
the  tendency  to  regard  its  practical  diagnostic  value  as  incommensurate 
with  the  difficulty,  trouble,  and  expense  involved  in  such  examinations. 
In  the  majority  of  instances  fractures  occur  in  those  portions  of  the  ribs 
which  are  most  inaccessible  for  the  radiographer,  namely,  between  the 
anterior  and  posterior  axillary  lines.  Side  views  would  frequently  be 
necessary,  but  satisfactory  lateral  radiographs  of  the  chest  are  usually 
difficult  to  obtain.  Fractures  frequently  occur  in  the  localities  where 
the  shadows  of  the  ribs  are  more  or  less  obscured  by  the  liver  and  heart, 
and  in  stout  subjects  the  examination  of  the  ribs  in  these  areas  is  by  no 
means  easy.  When  the  diagnosis  is  practically  certain  clinically,  an 
a:-ray  examination  is  not  necessary,  as  a  rule.  When  an  x-ray  examina- 
tion is  absolutely  necessary,  however,  it  can  usually  be  successfully  and 
satisfactorily  made,  even  in  the  presence  of  the  most  serious  obstacles. 
The  first  two  or  three  and  the  last  two  ribs  can  be  easily  shown  throughout 
their  entire  extent.  It  might  be  said  that  the  x-ray  examination  is 
easiest  in  those  localities  in  which  the  clinical  examination  is  most  diffi- 
cult, and  vice  versa.  The  x-ray  examination  is  especially  valuable  for 
the  detection  of  incomplete  and  fissured  fractures. 

Vertical  displacement  is  easily  shown,  but  this  is  not  the  case  when 
the  fragments  are  driven  in.  Separations  at  the  costochondral  junctions 
cannot  be  demonstrated  radiographically. 

The  interpretation  of  old  united  fractures  should  receive  careful 
consideration,  especially  in  medicolegal  cases.  Various  prominences 
and  irregularities  in  outline  are  to  be  found  in  many  ribs,  and  are  easily 
mistaken  for  old  fractures  surrounded  by  callus. 

Osteoperiostitis. — The  skiagraph  is  often  of  value  in  determining  the 
presence  of  disease  in  the  ribs,  its  exact  location,  and  the  extent  to  which 
the  bone  is  involved.  The  same  difficulties  are  to  be  encountered  as  in 
the  examination  for  fractures.  In  caries,  neither  the  presence  of  the 
condition  nor  the  extent  of  bony  destruction  is  likely  to  be  shown  unless 
the  process  has  reached  a  comparatively  advanced  stage.  A  gummatous 
osteitis  can  usually  be  observed  at  a  comparatively  early  stage  unless 
the  locality  is  inaccessible  to  the  x-ray  examination.  When  sinuses  exist, 
they  should  be  injected  with  bismuth  or  iodoform  before  the  examina- 
tion is  made. 


INJURIES  OF  THE  THORAX  AND  THORACIC  VISCERA         57 

Tumors. — Tumors  associated  with  appreciable  loss  of  bony  substance 
may  usually  be  demonstrated  if  the  region  is  accessible,  and  the  examina- 
tion in  such  instances  may  be  of  considerable  value.  Exostoses  are 
easily  shown.  Sometimes  a  small  exostosis,  by  pressure  upon  an  inter- 
costal nerve,  may  be  the  cause  of  intercostal  neuralgia,  and  under  such 
circumstances  an  x-ray  examination  might  be  the  only  way  in  which 
the  cause  of  the  trouble  could  be  discovered. 

Deformities. — Deformities  of  the  ribs  may  also  produce  symptoms 
of  nerve  pressure,  and  the  skiagraph  is  the  most  satisfactory  means  of 
revealing  the  cause.  The  particular  deformities  to  be  noted  are  those 
resulting  from  fractures,  either  in  the  form  of  permanent  displacement 
or  excessive  callus;  close  approximation  of  the  bones  such  as  is  seen  in 
marked  scoliosis;  or  those  due  to  rickets. 

The  Sternum.— The  sternum  is  one  of  the  most  difficult  bones  of  the 
body  to  radiograph,  and,  until  recently,  very  few  satisfactory  pictures  of 
it  have  been  made.  The  manubrium  is  the  easiest  portion  to  examine, 
but  considerable  ingenuity  is  required  to  obtain  skiagraphs  of  even  this 
small  portion.  The  x-rsij  examination  for  fractures  or  dislocations  at 
the  junction  of  the  manubrium  and  gladiolus  is  unsatisfactory,  but 
fortunately  the  diagnosis  is  easily  determined  clinically. 

Disease  and  tumors  are  likewise  difficult  to  demonstrate  for  the  same 
reasons,  and  an  a:-ray  examination  is  of  practically  no  value  unless  the 
extreme  upper  portion  of  the  bone  is  involved. 

The  Dorsal  Vertebrae. — As  a  rule,  this  is  the  most  difficult  portion 
of  the  spine  to  radiograph  satisfactorily,  mainly  because  clear  details  of 
the  vertebrae  are  obscured  by  the  superimposed  shadows  of  the  great 
vessels,  heart,  liver,  and  sternum.  In  thin  subjects,  clear  details  are 
easily  obtained,  but  the  stouter  the  individual  the  more  unsatisfactory 
the  skiagraph. 

Fractures. — Fractures  of  the  dorsal  vertebrae  can,  of  course,  be  easily 
demonstrated  under  favorable  circumstances.  The  difficulties  attend- 
ing the  a;-ray  examination  of  this  portion  of  the  spine  in  a  case  of  recent 
fracture  are  to  be  added  to  those  just  mentioned.  Lateral  views  when 
they  are  obtainable  show  the  bodies  to  the  best  advantage,  especially  in 
dislocations,  but  the  upper  dorsal  vertebrae  can  seldom  be  skiagraphed  in 
this  direction,  and  it  is  useless  to  attempt  a  lateral  radiograph  in  stout 
subjects. 

Caries. — Caries  of  the  bodies  of  the  dorsal  vertebrae  is  difficult  or 
impossible  to  demonstrate  unless  the  destruction  has  advanced  far 
enough  for  the  disease  to  be  clinically  evident  beyond  question.  Occa- 
sionally, in  very  thin  subjects,  Pott's  disease  has  been  recognized  at  a 
very  early  stage  by  the  skiagraph.  In  young  children  the  examination 
is  always  unsatisfactory  because  of  the  incomplete  ossification  of  the 
vertebral  bodies. 

Tumors. — The  x-rsij  examination  for  tumors  of  this  portion  of  the  spine 
is  of  little  practical  value.  In  rare  instances,  however,  the  skiagraph 
may  give  some  valuable  information. 

To  credit  the  radiograph  with  any  practical  diagnostic  value  in  con- 
nection with  tumors  of  the  spinal  cord  is,  of  course,  absurd. 


58      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

Scoliosis. — Scoliosis  is  easily  demonstrated,  and  the  extent  of  the 
deformity,  the  degree  of  rotation  of  the  vertebral  bodies,  and  many  of 
the  secondary  deformities,  such  as  those  of  the  ribs,  can  be  readily 
shown.  Details  are  not  so  essential  in  this  condition,  but,  as  a  rule, 
they  are  unusually  clear  because  the  curve  of  the  spine  carries  the 
vertebrae  away  from  some  of  the  structures  which  normally  obscure 
them. 

Arthritis, — ^Arthritic  conditions  involving  the  spine,  such  as  the  type 
associated  with  chronic  osteo-arthritis,  for  example,  cannot  be  demon- 
strated unless  there  is  some  marked  structural  change.  Bony  and  carti- 
laginous absorption  are  to  be  noted  in  advanced  stages  of  the  atrophic 
types,  and  excessive  bony  deposits  in  the  hypertrophic  type. 

Foreign  Bodies. — ^The  examination  for  foreign  bodies  in  the  thorax, 
other  than  those  associated  with  gunshot  injuries,  requires  special  men- 
tion because  of  the  localities  in  which  they  lodge  and  the  avenues  of  their 
introduction,  both  of  which  are  peculiar  to  this  portion  of  the  body. 

Esophagus. — ^The  majority  of  the  cases  examined  for  suspected 
bodies  lodged  in  the  esophagus  are  young  children.  Many  of  the 
articles  which  are  swallowed  and  which  are  too  large  to  pass  through  are 
first  halted  at  the  uppermost  constriction  where  the  pharynx  and  esopha- 
gus join.  Here  they  may  be  easily  palpable  through  the  mouth,  and,  if 
so,  can  be  removed  without  the  assistance  of  localization  by  the  radio- 
graph. The  level  at  which  the  radiographer  usually  finds  bodies  lodged 
is  about  that  of  the  suprasternal  notch.  This  point  is  slightly  below  the 
first  constriction  and  slightly  above  the  next  lower  one,  where  the  left 
bronchus  crosses  the  esophagus.  The  point  of  lodgement,  however, 
depends  somewhat  upon  the  nature  and  size  of  the  object  swallowed. 
Straight  pins  and  small  open  safety  pins  passing  point  downward  may 
lodge  anywhere,  although  the  former  invariably  pass,  and  even  the  latter 
usually  do.  Long  straight  pins  are  much  more  apt  to  lodge  than  short 
ones  if  they  pass  point  downward.  Large  open  safety  pins  will  usually 
lodge  high  up  in  children  if  they  pass  the  first  constriction. 

In  children,  the  majority  of  the  objects  found  lodged  at  the  point  just 
mentioned  are  coins — ^more  often  pennies,  but  sometimes  nickels.  Dimes 
will  usually  pass,  and  larger  coins  will  not  enter  the  esophagus  of  children, 
although  a  half-dollar  has  been  found  lodged  at  this  level  in  the  esophagus 
of  an  adult.  Other  articles  commonly  swallowed  by  children,  and  likely 
to  lodge,  are  buttons,  jackstones,  and  rounded  flat  metal  whistles.  In 
rare  instances,  tooth  plates  have  been  swallowed  by  adults  and  have 
lodged  in  the  esophagus. 

An  x-ray  examination  is  practically  imperative  in  all  cases  in  which  the 
lodgement  of  a  foreign  body  in  the  esophagus  is  suspected.  Primarily 
it  is  necessary  in  order  to  determine  with  absolute  certainty  whether 
a  body  has  lodged  or  not.  In  addition,  it  will  show  the  nature  of  the 
object  and  its  exact  location,  so  that  the  su/geon  is  at  once  able  to  decide 
upon  the  most  appropriate  method  for  extraction. 

The  examination  for  less  dense  objects,  such  as  pieces  of  chicken  bone 
or  nut  shells,  is  usually  somewhat  different  from  that  in  case  of  the  much 


INJURIES  OF  THE  THORAX  AND  THORACIC  VISCERA  59 

denser  ones,  and  is  far  more  difficult.  The  radiographer  should,  there- 
fore, have  some  previous  knowledge  of  the  nature  of  the  object  for  which 
he  is  to  examine.  Fish  bones  are  extremely  difficult  and  usually  impos- 
sible to  demonstrate  in  the  skiagraph,  but  they  usually  pass,  and  the 
sensation  referable  to  their  lodgement  is  generally  due  to  the  trauma 
produced  by  their  passage. 

The  Air  Passages. — Many  objects  which  may  gain  entrance  into  and 
become  lodged  in  either  the  larynx,  trachea,  or  bronchi  cannot  be  detected 
by  means  of  the  a;-rays,  because  of  their  lack  of  sufficient  density  to  cast 
shadows.  Some  objects,  of  comparatively  slight  density,  if  lodged  in 
the  larynx  or  upper  portion  of  the  trachea,  may  be  more  or  less  plainly 
shown  in  a  lateral  view  of  the  neck  when  a  radiograph  made  in  the 
anteroposterior  direction  would  give  no  indication  of  their  presence. 

Gunshot  Injuries. — Primarily  the  essential  object  of  the  examination  is 
to  determine  the  presence  of  the  missile;  this  the  skiagraph  does  invari- 
ably. It  will  also  show  the  exact  location  of  the  missile  and  thereby 
aid  in  determining  its  accessibility  for  removal.  Methods  of  accurate 
localization  by  means  of  special  instruments  of  precision  may  be  em- 
ployed advantageously  in  some  instances,  but,  as  a  rule,  fore-and-aft  and 
lateral  views  will  suffice. 

Aneurysms. — Radiographs  have  frequently  shown  aneurysms  when 
their  presence  could  not  be  detected  clinically,  but  in  many  such  instances 
the  pictures  have  been  misinterpreted  and  the  x-ray  diagnosis  has  been 
incorrect.  Moreover,  the  skiagraph  has  not  infrequently  failed  to  reveal 
the  presence  of  an  aneurysm  that  undoubtedly  existed.  But  ordinarily 
the  a;-ray  diagnosis  is  not  especially  difficult  in  the  hands  of  a  careful 
examiner  with  a  reasonable  amount  of  experience,  although  there  are 
instances  in  which  it  is  extremely  difficult. 

There  is,  perhaps,  no  other  condition  better  adapted  to  examination  by 
the  fluoroscope.  It  is  a  most  convenient  method  for  both  diagnosis  and 
study  of  thoracic  aneurysms,  and  reveals  some  features  that  cannot  be 
shown  readily  by  the  skiagraph.  Its  superiority  over  the  latter  for 
diagnosis  alone,  however,  is  questionable,  and  any  special  advantages 
it  may  possess  certainly  do  not  justify  the  risks  entailed  in  its  routine  use, 
since  there  is  no  way  of  employing  the  fluoroscope  with  absolute  safety. 
Improvements  in  apparatus  have  made  it  possible  to  radiograph  the  chest 
of  the  average  individual  in  a  fraction  of  a  second,  and  satisfactory 
stereoscopic  radiographic  examinations  of  the  thorax  are  within  the 
range  of  possibility.  When  this  state  of  perfection  has  been  realized, 
the  accuracy  of  the  x-ia,j  diagnosis  of  aneurysms  will  be  markedly  in- 
creased, and  the  fluoroscope  will  practically  cease  to  hold  any  special 
advantage  beyond  the  observation  of  pulsation. 

Aneurysms  of  the  aortic  arch  are  peculiarly  adapted  to  examination 
by  means  of  the  a:-rays  because  of  the  transparent  structure  of  the  sur- 
rounding lung  tissue.  The  heart  and  aortic  arch  are  readily  observed 
unless  other  abnormal  shadows  obscure  them.  The  outlines  of  the 
normal  aorta  are  nearly  or  entirely  overshadowed  by  the  spine  and 
sternum,  but  this  is  unimportant  for  the  reason  that  any  enlargement  or 


60      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

displacement  of  the  vessel  is  always  perceptible  unless  obscured  by 
abnormal  structures. 

As  to  the  interpretation  of  a  radiograph  taken  for  aneurysm,  if  there 
is  no  marked  enlargement  of  the  aortic  shadow,  aneurysm  may  be 
excluded.  If,  however,  it  is  apparently  abnormally  enlarged,  the  next 
question  to  decide  is  as  to  whether  this  shadow  arises  from  the  aorta  or 
is  due  to  some  other  condition  that  may  be  present.  This  is  often  a 
difficult  point  to  determine  with  certainty.  If  the  abnormal  shadow  can 
be  positively  identified  as  that  of  the  aorta,  it  is  often  necessary  to  deter- 
mine next  whether  the  condition  is  an  aneurysm  or  a  dilated  aorta.  This 
too  is  sometimes  a  difficult  problem,  and,  as  a  rule,  the  correct  solution 
requires  judgment  and  experience. 

Radiographically,  aneurysms  of  this  locality  may  be  classed  primarily 
as  diffuse  and  those  which  are  more  or  less  localized,  or  sacculated. 

Diffuse  aneurysms  involve  the  entire  arch,  or  a  greater  part  of  it. 
When  small,  they  may  be  mistaken  for  a  condition  known  as  dilated 
aorta. 

Localized,  or  sacculated,  aneurysms  can  be  easily  detected,  as  a  rule, 
in  any  of  the  three  portions  of  the  arch.  A  small  one  involving  the  trans- 
verse portion  and  extending  directly  upward  may  escape  detection, 
especially  in  stout  subjects,  because  it  is  more  or  less  obscured  by  the 
shadow  of  the  spine.  A  dilated  or  hypertrophied  left  heart  may  be 
confusing  in  connection  with  a  suspected  aneurysm  of  the  descending 
portion  of  the  arch. 

Aneurysms  involving  the  descending  portion  of  the  thoracic  aorta,  or 
the  part  of  the  vessel  below  the  arch,  are  much  more  difficult  to  demon- 
strate because  of  the  overlying  cardiac  shadow.  They  are  comparatively 
uncommon,  however.  They  usually  involve  that  portion  of  the  vessel 
just  above  the  point  where  it  passes  through  the  diaphragm. 

Differential  Diagnosis. — Radiographically,  aneurysmal  shadows  are  to 
be  differentiated  from  those  of  the  following  conditions. 

1.  Mediastinal  Tumors. — ^This  diagnosis  is  not  difficult,  provided  the 
shadow  of  the  aorta  can  be  determined  in  case  of  tumor  or  the  enlarged 
shadow  can  be  positively  identified  as  that  of  the  vessel  in  case  of  aneu- 
rysm. If  the  identity  is  questionable  in  case  of  a  single  large  shadow  of 
considerable  density  and  of  uniform  outline,  the  diagnosis  is  difficult. 

2.  Enlarged  Mediastinal  and  Bronchial  Lymph  Glands. — ^An  experi- 
enced examiner  is  not  apt  to  confuse  the  shadows  of  such  structures  with 
the  appearance  of  aneurysm  if  the  skiagraphic  details  are  satisfactorily 
clear. 

3.  Localized  Empyema  or  Thickened  Pleura. — ^The  skiagraphic  appear- 
ance may  occasionally  bear  some  resemblance  to  that  of  aneurysm. 
Under  such  circumstances  the  clinical  history  of  the  case  is  essential  in 
making  a  correct  diagnosis. 

Localized  Thickened  Pleura. — ^The  same  remarks  are  applicable  in 
connection  with  this  condition. 

5.  Tortuosity  or  Displacement. — Familiarity  with  the  normal  varia- 
tions in  placement,  size,  and  contour  are  essential  to  the  correct  inter- 
pretation of  abnormal  appearances. 


INJURIES  OF  THE  THORAX  AND  THORACIC  VISCERA  61 

6.  Dilated  Aorta. — Under  certain  circumstances  the  distinction  from 
aneurysm  may  be  impossible  because  of  the  presence  of  other  diffuse 
shadows  having  a  density  equal  to  or  greater  than  that  of  the  vessel. 

Liquid  effusions  of  any  kind  filling  one  or  both  pleural  cavities  or  the 
pericardium  render  the  radiographic  diagnosis  of  aneurysm  difficult  or 
impossible.  Our  knowledge  concerning  the  diagnostic  value  of  the 
rc-rays  in  regard  to  aortic  aneurysm  may  be  summarized  as  follows: 

The  appearance  of  normal  shadows  in  the  region  of  the  thoracic  aorta 
in  a  skiagraph  in  which  the  details  are  satisfactorily  clear  is  the  most 
reliable  evidence  against  aneurysm.  Its  presence  or  absence  can  be 
demonstrated  with  accuracy  in  the  large  majority  of  instances.  Most 
errors  arise  from  inexperience,  poor  negatives,  faulty  technique,  or 
failure  of  the  clinician  to  cooperate  with  the  radiographer  in  the  inter- 
pretation of  the  skiagraph,  especially  in  doubtful  cases.  An  a;-ray  diag- 
nosis may  be  impossible  in  rare  instances.  A  skiagraphic  diagnosis  can 
often  be  made  at  a  very  early  stage  of  the  disease  and  sometimes  even 
earlier  than  any  definite  clinical  signs  can  be  detected.  When  aneu- 
rysm is  suspected,  but  the  clinical  diagnosis  is  uncertain,  the  x-ray 
examination  is,  in  the  majority  of  instances,  the  most  valuable  and 
accurate  means  for  determining  its  presence  or  absence.  Even  when 
the  clinical  evidence  seems  apparently  unquestionable,  the  skiagraph  not 
only  gives  confirmatory  evidence,  but  it  will,  in  addition,  accurately 
demonstrate  the  size  and  position  of  the  aneurysm,  and  is  always  a 
safeguard  against  a  possible  error. 

Innominate  and  subclavian  aneurysms  are  as  well  adapted  to  a;-ray 
examination  as  are  those  of  the  aorta,  although  their  detection  is  usually 
more  difficult.  For  this  reason,  and  because  of  their  comparative 
infrequency,  they  are  likely  to  be  overlooked  when  their  presence  is 
unsuspected.  A  skiagraphic  examination  before  an  operation  upon  an 
aneurysm  of  one  of  these  vessels  is  of  importance  for  determining  its 
size,  character,  and  extent,  and  the  possibility  of  associated  involve- 
ment of  the  aorta  by  an  aneurysmal  dilatation  independent  of  or 
continuous  with  that  of  the  smaller  vessel. 

The  Lungs  and  Pleura. — ^The  surgical  affections  of  these  structures, 
in  which  the  x-ray  examination  is  applicable  for  purposes  of  diagnosis, 
are  abscess  and  gangrene  of  the  lungs  and  pleural  effusions  and  empyema. 

Exposure  of  the  chest  to  x-rays  during  the  acute  stage  of  'pneumonia 
is  not  advisable  unless  it  seems  absolutely  necessary  from  the  point  of 
view  of  immediate  surgical  intervention. 

Abscess  of  the  Lung. — The  distinction  between  abscess  and  localized 
empyema  is  one  that  is  often  required,  and  one  that  is  sometimes  difficult 
to  make  clinically.  The  radiograph  is  a  reliable  means  of  differentiating 
between  these  two  conditions. 

With  reasonable  care  and  experience  the  skiagraphic  appearances  of 
abscess  and  cavity  should  not  be  confused.  A  knowledge  of  the  clinical 
history  of  the  case  is  always  necessary  as  a  safeguard  against  errors  in 
the  interpretation  of  the  pictures. 

Gangrene. — If  this  condition  is  suggested  clinically  the  skiagraph  may 
be  a  valuable  aid  in  the  diagnosis.     It  is  unquestionably  of  value  in  the 


62      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

localization  of  the  affected  area.  Here  especially  a  knowledge  of  the 
clinical  data  is  essential. 

Pleural  Effusions  and  Empyema. — The  presence  of  fluid  in  the  pleural 
cavity,  whether  serum,  blood,  or  pus,  can  be  accurately  and  easily  demon- 
strated by  the  skiagraph.  The  a;-ray  diagnosis  is  especially  valuable 
in  connection  with  localized  effusions  and  empyemas.  The  skiagraph 
is  likely  to  be  inadequate  or  misleading  unless  careful  attention  is  paid 
to  certain  important  points,  such  as  the  position  of  the  patient,  the 
position  of  the  plate  and  tube,  etc.  The  skiagraphic  appearance  of 
an  area  of  greatly  thickened  pleura  may  closely  resemble  that  of  a 
localized  effusion  or  empyema,  and  vice  versa,  and  this  fact,  therefore, 
should  not  be  overlooked. 

Subphrenic  Abscess. — ^This  condition  may  be  appropriately  mentioned 
here  because  of  the  question  of  differential  diagnosis  from  certain  intra- 
thoracic conditions,  especially  empyema.  Under  certain  circumstances, 
and  with  the  exercise  of  care  and  ingenuity,  a  subphrenic  abscess  may 
be  diagnosticated  by  means  of  the  a:;-ray  examination. 

SURGICAL  AFFECTIONS  OF  THE  ABDOMEN  AND  PELVIS. 

Considering  the  number  and  the  variety  of  pathological  conditions 
associated  with  the  abdominal  organs,  the  field  for  x-rsij  diagnosis  is  a 
comparatively  limited  one.  Perhaps  this  method  of  examination  is 
most  helpful  in  the  diagnosis  of  certain  conditions  of  the  urinary  and 
the  gastro-intestinal  tract. 

Urinary  Tract. — Renal  Calculus. — The  radiographic  examination  is 
the  most  valuable  and  the  most  uniformly  accurate  method  at  our  com- 
mand.    It  must  not,  however,  be  regarded  as  infallible. 

No  skiagraphic  examination  for  renal  calculus  can  be  entirely  satis- 
factory unless  the  patient  has  received  an  adequate  preliminary  prepara- 
tion. This  implies  that  the  stomach  should  contain  little  or  no  food, 
that  the  intestinal  tract  should  be  nearly  empty,  particularly  in  regard 
to  gas,  and  that  no  pills  or  tablets  should  have  been  taken  after  a  time 
which  would  allow  any  chance  of  one  remaining  in  the  intestinal  tract 
when  the  examination  is  made.  Salol  in  particular  casts  a  distinct 
shadow. 

Given  a  well-prepared  patient,  an  efficient  apparatus,  and  a  skilful 
operator  and  interpreter,  the  most  but  not  all  of  the  sources  of  failure 
or  error  are  eliminated. 

The  presence  of  excessive  amounts  of  fat  in  the  abdominal  walls  and 
omentum,  thick  abdominal  muscles,  tumors,  a  pregnant  uterus,  or 
ascites  may  obscure  the  shadow  of  a  stone. 

A  skiagraph  of  the  kidney  area,  to  be  considered  reliable  for  diagnosis, 
should  show  the  shadows  of  the  psoas  muscles  at  least,  and,  to  be  still 
more  certain  of  accuracy,  it  should  have  sufficient  detail  to  show  the 
shadows  of  the  kidneys  in  addition.  An  absolute  diagnosis,  whether  it 
be  positive  or  negative,  should  not  be  made  from  a  single  skiagraph 
or  even  one  examination. 


SURGICAL  AFFECTIONS  OF  THE  ABDOMEN  AND   PELVIS      63 

Shadows  similar  to  those  of  calcuh  may  be  cast  by  calcified  lymph 
glands,  circumscribed  collections  of  pus  in  the  kidney,  small  enteroliths, 
and  fecal  or  other  concretions  in  the  lumen  of  the  appendix.  The  pos- 
sibility of  error  from  such  sources  is  influenced  to  some  extent  by  the 
skill  and  experience  of  the  examiner,  though  it  cannot  be  altogether 
eliminated. 

In  the  skiagraphs  of  pelves  of  many  normal  individuals  will  be  found 
shadows  which  have  an  appearance  practically  identical  with  that  of 
ureteral  calculi.  The  position  of  such  shadows  often  distinguishes 
them  from  those  of  calculi.  This  is  not  always  the  case,  and  in  some 
instances  the  only  way  of  proving  the  exact  identity  of  the  shadows  is  to 
radiograph  the  patient  with  a  catheter  and  stilette  in  the  ureter,  or  to 
make  a  stereoscopic  examination,  but  the  former  method  is  preferable. 

Most  of  the  extraureteral  shadows  are  due  to  the  presence  of  phle- 
boliths  in  the  pelvic  veins  or  to  small  sesamoids  in  the  tendons  attached 
to  the  ischiatic  spine.  A  less  frequent  source  of  error  is  the  presence  of 
calcified  pelvic  lymph  glands.  Should  one  of  these  be  located  about 
the  line  of  the  ureter,  it  is  practically  impossible  to  distinguish  it  radio- 
graphically  from  a  ureteral  calculus  except  by  skiagraphing  after  cathe- 
terization. A  calculus  lodged  in  the  portion  of  the  ureter  overlying  the 
bony  pelvis,  an  infrequent  position,  may  be  obscured  by  the  shadow  of 
the  bone. 

Nephroptosis. — The  displaced  kidney  is  more  readily  shown  than  the 
normally  placed  organ.  The  preliminary  preparation  is  that  indicated 
in  the  examination  for  calculus. 

Tumors. — Under  favorable  conditions  the  skiagraph  will  in  many 
instances  render  valuable  assistance  in  the  diagnosis  of  renal  tumors, 
especially  in  regard  to  the  identification  of  those  in  which  the  renal  origin 
is  uncertain. 

Pyonephrosis. — In  many  instances  the  skiagraph  will  aid  materially 
in  the  diagnosis  of  circumscribed  abscess  in  the  kidney  substance.  The 
shadow  of  such  a  lesion  has  sometimes  been  mistaken  for  stone. 

Hydronephrosis. — ^The  shadow  of  the  enlarged  kidney  and  sometimes 
a  faint  shadow  of  a  dilated  pelvis  are  the  skiagraphic  data  obtainable 
in  this  condition  under  favorable  circumstances. 

Perinephric  Abscess. — ^The  skiagraph  is  only  of  negative  value  in 
diagnosis. 

Vesical  Calculus. — ^The  x-raj  diagnosis  of  vesical  calculus  is  more 
difficult  and  more  uncertain  than  that  of  renal  calculus.  This  is  mainly 
because  of  the  position  and  anatomical  relations  of  the  bladder  and  the 
stone  and  the  consistency  of  the  majority  of  vesical  calculi.  Conserva- 
tively speaking,  we  may  regard  the  skiagraphic  examination  as  a  very 
valuable  and  fairly  accurate  means  of  diagnosis  in  vesical  calculus, 
but  having  a  higher  percentage  of  error  than  in  connection  with  renal 
calculus.  The  preliminary  preparation  is  that  called  for  in  renal  exami- 
nations. 

Prostatic  Calculi. — ^The  presence  of  calculi  may  be  read'.y  detected, 
but  distinction  from  vesical  calculi  is  more  difficult. 


64      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

Foreign  Bodies. — ^The  presence  of  foreign  bodies  in  the  bladder,  intro- 
duced accidentally  or  partially  by  intent,  is  easily  determined  by  the 
skiagraph. 

Liver  and  Gall  Bladder.— In  thin  or  moderately  thin  subjects  the 
general  outline  of  the  liver  is  easily  obtained  in  the  skiagraph.  The 
radiograph  is  especially  accurate  in  demonstrating  the  position  of  the 
organ,  especially  its  lower  right  border.  This  is  important  in  connection 
with  the  examination  of  cases  of  gastroptosis.  The  size  of  the  liver  can 
be  estimated  from  the  skiagraph,  though  the  shadow  is  often  misleading. 

In  thin  subjects  abscesses  and  cysts  of  the  liver  may  sometimes  be 
detected.     Sinuses  may  be  outlined  by  previous  bismuth  injections. 

Biliary  Calculus.— As  yet,  the  rr-ray  examination  in  connection  with 
biliary  calculus  has  proved  so  unsatisfactory  and  so  unreliable  as  to 
render  it  of  no  practical  value  in  the  diagnosis  of  this  condition.  In 
comparatively  rare  instances  and  under  especially  favorable  conditions 
a  positive  diagnosis  has  been  made,  and  confirmed  later,  but  a  negative 
x-ray  diagnosis  has  so  far  been  absolutely  valueless.  Notwithstanding 
the  unsatisfactory  results  in  the  past,  it  is  more  than  likely  that  the  rapid 
strides  now  being  made  in  the  improvement  of  apparatus  and  methods 
will  tend  to  make  the  a;-ray  diagnosis  of  gallstones  sufficiently  reliable 
in  the  near  future  to  be  dependable,  but  only  under  certain  favorable 
conditions.  It  will  be  necessary,  however,  to  limit  the  use  of  the  skia- 
graphic  examination  strictly  to  those  cases  in  which  the  latter  term  is 
applicable.  "Favorable  conditions"  would  imply  comparatively  thin 
subjects;  the  location  of  stones  in  the  bile  ducts,  especially  the  common 
duct,  and,  if  in  the  gall-bladder,  the  absence  of  distention  with  bile;  and 
the  absence  of  conditions  which  would  tend  to  interfere  with  the  impor- 
tant details  essential  to  the  success  of  such  an  examination.  Careful 
and  thorough  preliminary  preparation  of  the  patient  is  of  course  impera- 
tive. The  size  of  the  stones  would  influence  the  likelihood  of  their  detec- 
tion, and  the  presence  of  lime  salts  would  render  it  more  certain. 

The  Pancreas. — ^The  attempt  to  employ  the  skiagraph  in  connection 
with  the  examination  of  the  pancreas  has  with  very  rare  exceptions  met 
with  no  success.  The  x-raj  examination  is,  therefore,  of  no  practical 
value  in  the  diagnosis  of  pancreatic  affections  except  possibly  calculus. 

The  Spleen. — ^The  spleen  is  easily  skiagraphed,  provided  the  patient 
is  not  too  stout,  but  there  is  seldom  any  practical  use  for  the  x-ray 
examination  of  this  organ  beyond  the  determination  of  its  position. 

Abdominal  Aneurysms. — ^Aneurysms  of  the  abdominal  aorta  are 
difficult  to  demonstrate  satisfactorily  by  means  of  the  skiagraph  except 
in  thin  subjects.  It  is  possible  that  in  some  of  the  cases  in  which  this 
portion  of  the  vessel  is  the  supposed  seat  of  the  lesion  the  aneurysm  is 
really  in  the  lower  extremity  of  the  descending  thoracic  aorta. 

Foreign  Bodies. — Foreign  bodies  in  the  abdomen  and  pelvis  can 
usually  be  localized  within  reasonably  accurate  limits.  Absolute  localiza- 
tion is  difficult  because  the  movements  of  the  abdominal  walls  and  the 
constant  variations  in  the  dimensions  of  the  abdomen  are  serious  ob- 
stacles to  the  use  of  special  localization  apparatus. 


THE  GASTRO-INTESTINAL  TRACT  65 

Tumors. — Intra-abdominal  tumors  in  the  early  stage  of  their  growth 
cannot  be  detected  by  radiographic  examination;  later  the  shadows  may 
show  the  extent  and  location  of  tumors  and  demonstrate  the  structures 
from  which  they  spring  or  with  which  they  are  connected. 

The  Lumbar  Spine. — ^This  portion  of  the  spine  is  easily  and  satis- 
factorily radiographed  unless  the  subject  is  very  stout.  Often  such 
comparatively  slight  injuries  as  fractures  of  the  transverse  processes  can 
be  recognized  in  no  other  way.  Marked  changes  can  be  seen  in  cases  of 
advanced  spinal  caries,  but  rarely  any  in  the  beginning.  Sinuses  may 
be  followed  after  preliminary  injection  with  bismuth  or  iodoform  sus- 
pension. The  changes  of  lateral  curvature,  typhoid  spine,  and  spondy- 
litis deformans  are  clearly  shown.  The  radiographic  examination  of 
spina  bifida  is  unsatisfactory  in  its  results  and  is  of  little  or  no  practical 
value. 

THE  GASTRO-INTESTINAL  TRACT. 

In  the  application  of  the  x-rays  in  the  diagnosis  of  abdominal  and  pelvic 
conditions,  the  examination  of  the  stomach  and  large  bowel  may  now  be 
regarded  as  next  in  importance  to  that  for  renal  calculus.  These  hollow 
viscera  are  rendered  distinguishable  only  by  the  shadows  of  some  opaque 
substance  within  them,  usually  the  subnitrate  of  bismuth — introduced 
by  mouth  in  the  examination  of  the  esophagus  and  stomach,  and  either 
by  mouth  or  rectum  in  the  case  of  the  large  intestine.  All  radiographs 
must  be  anatomically  accurate,  and  must  be  so  interpreted  as  to  convey 
the  correct  impression  of  the  existing  conditions  and  relations  which 
they  are  intended  to  represent. 

Esophagus. — In  the  examination  of  this  portion  of  the  tract,  accurate 
data  can  be  obtained  in  regard  to  the  presence,  location,  and  extent  of 
strictures,  dilatations,  and  congenital  and  acquired  diverticula.  In  some 
instances  in  which  comparatively  extensive  growths  are  the  causes  of 
stenoses  the  skiagraph  is  capable  of  furnishing  many  important  and 
reliable  facts  concerning  the  condition. 

Stomach. — Perhaps  the  widest  application  of  this  method  is  in  the 
examination  of  the  stomach.  The  important  data  directly  or  indirectly 
obtainable  are :  (1)  The  exact  outlines,  position,  and  size  of  the  stomach 
under  varying  conditions ;  (2)  a  definite  knowledge  of  the  factors  directly 
or  indirectly  concerned  in  the  production  of  ptosis  and  dilatation,  such 
as  the  position  of  the  pylorus,  the  actual  existence  or  the  likelihood  of  a 
duodenal  kink,  the  length  of  the  gastrohepatic  ligament,  the  degree  of 
tonicity  or  relaxation  of  the  muscular  coat,  the  existence  of  ptosis 
of  the  liver,  the  possibility  of  traction  by  a  ptosed  colon,  and  in  some 
instances  the  presence  of  causes  of  pyloric  obstruction  other  than  kinks; 

(3)  an  approximate  knowledge  concerning  the  motility  of  the  organ; 

(4)  valuable  suggestions  in  regard  to  the  most  appropriate  method  of 
treatment  of  the  gastroptosis  and  dilatation;  (5)  definite  knowledge  of 
the  actual  mechanical  and  anatomical  results  derived  from  any  methods 
of  treatment  employed. 

5 


(36      THE  APPLICATION  OF  X-RAYS  IN  SURGICAL  DIAGNOSIS 

The  presence   of  "hour-glass"  constrictions  is  readily  determined. 

The  skiagraph  is  capable  not  only  of  demonstrating  the  above-men- 
tioned facts  with  dependable  accuracy,  but  also  with  more  certainty  and 
uniformity,  as  a  rule,  than  any  other  methods  at  our  command,  and  in 
many  instances  the  information  derived  from  the  x-va,j  examination  is 
practically  unobtainable  by  any  other  means. 

Until  recently  the  a;-rays  promised  little  in  the  early  diagnosis  of  car- 
cinoma, but  quite  recent  advances  in  stomach  examination  have  made 
it  possible  to  obtain  fairly  reliable  data  that  will  frequently  verify  or 
strengthen  an  uncertain  clinical  diagnosis  at  an  early  stage  of  the  disease. 

Small  Intestine. — ^The  examination  of  this  portion  of  the  tract  has 
so  far  been  unsatisfactory.  Its  successful  application  has  been  practically 
limited  to  the  detection  and  location  of  various  forms  of  obstruction,  in 
which  relation  the  skiagraphic  information  has  occasionally  proved  most 
useful. 

Colon. — Next  in  importance  to  the  examination  of  the  stomach  by 
this  method  is  the  examination  of  the  colon.  It  is  undoubtedly  the  most 
reliable  and  accurate  means  we  have  of  determining  displacements  of 
this  portion  of  the  gut.  The  presence  and  the  location  of  obstructions 
are  readily  shown.  In  connection  with  obstruction  due  to  newgrowths, 
it  is  often  possible  to  determine  whether  the  latter  involves  the  walls  of  the 
colon  or  encroaches  upon  the  lumen  by  pressure  from  without.  In  some 
instances  the  presence  of  adhesions  between  loops  of  displaced  large 
bowel  may  be  suggested.  In  cases  of  fecal  fistula,  it  is  possible,  after 
injection  of  bismuth  through  the  external  opening,  to  determine  by  the 
skiagraph  the  portion  of  the  bowel  into  which  the  fistula  opens. 

Sigmoid. — This  portion  of  the  bowel  is  also  easily  examined  by 
this  method.  Its  important  application  is  in  the  diagnosis  of  ptosis, 
redundancy,  and  obstructions. 


INJURIES  AND  SURGICAL  AFFECTIONS  OF  THE  SOFT  PARTS. 

The  field  of  application  for  the  a;-ray  examination  in  connection  with 
injuries  and  other  surgical  affections  of  the  soft  parts  is  comparatively 
limited.  The  few  instances  in  which  it  is  applicable  will  be  given  brief 
mention. 

Arteriosclerosis. — The  presence  of  advanced  sclerosis  in  any  of  the  main 
vessels  of  the  extremities  and  of  their  larger  branches  is  easily  determined 
by  means  of  the  skiagraph.  Although  its  employment  for  this  purpose 
is  seldom  necessary,  it  may  occasionally  be  of  some  practical  value. 

Traumatic  Aneurysms. — ^The  skiagraph  is  sometimes  useful  in  connec- 
tion with  this  condition,  especially  in  popliteal  aneurysms. 

Bursitis. — In  certain  localities  the  skiagraph  serves  a  very  useful 
purpose  in  the  diagnosis  of  this  condition,  especially  in  connection  with 
the  deltoid  bursa. 

Myositis. — ^The  skiagraph  is  especially  useful  as  a  means  of  differential 
diagnosis  in  this  condition.     Myositis  ossificans  is  the  particular  type 


INJURIES  AND  SURGICAL  AFFECTIONS  OF  THE  SOFT  PARTS     57 

in  which  it  is  directly  applicable  for  the  examination  of  the  condition 
itself. 

Rupture  of  Muscles. — ^The  skiagraph  is  sometimes  useful  in  the  diagnosis 
of  this  injury. 

Painful  Stumps. — ^The  a;-ray  examination  of  painful  stumps  is  often 
the  only  satisfactory  means  of  determining  the  cause  of  this  sequel 
of  amputations. 


CHAPTER    III. 

INFLAMMATION. 

Inflammation,  the  tissue  reaction  against  injury,  has  for  its  end  the 
removal  of  necrotic  material,  the  neutralization  of  toxins,  and  the  restora- 
tion of  structural  continuity. 

Following  trauma  without  infection,  the  local  symptoms  are  slight  and 
transitory,  nor  are  there  constitutional  symptoms  other  than  those  inci- 
dent to  the  shock  of  injury  and  the  fever  of  reaction  and  absorption. 
By  the  third  day  these  symptoms  should  have  disappeared  or  be  obvi- 
ously subsiding. 

Following  infection,  the  local  and  constitutional  symptoms  become 
progressively  more  marked,  and  are  well  pronounced  by  the  third  to  the 
fifth  day,  thereafter  running  a  course  dependent  on  freedom  of  drainage, 
virulence  of  infection,  and  tissue  resistance. 

The  local  symptoms  of  inflammation  are  heat,  redness,  swelling,  pain, 
tenderness,  and  alteration  of  function. 

Heat  and  redness  can  be  detected  only  in  inflammations  of  the  surface 
or  those  lying  near  it.  Swelling  can  be  noted  in  parts  which  are  normally 
palpable  through  the  parietes.  The  surface  edema  of  deep  infection  is 
a  valuable  localizing  sign.  Tenderness  and  pain,  usually  associated  with 
protective  muscular  rigidity,  are  often  the  symptoms  which  indicate  the 
seat  of  a  deep-seated  inflammation. 

The  constitutional  symptom  of  inflammation  is  fever,  usually  accom- 
panied by  leukocytosis  of  the  polymorphonuclear  type. 

High  fever,  rapid  pulse,  and  a  pronounced  leukocytosis  are  indicative 
of  an  organism  stimulated  to  powerful  reaction  against  an  active 
infection.  Moderate  fever,  slight  leukocytosis,  and  running  pulse 
suggest  an  organism  overwhelmed  by  the  infection. 

In  accordance  with  the  infecting  agent,  its  virulence  and  the  tissue 
resistance  inflamma^pn  may  be  circumscribed  or  diffuse,  acute  or  chronic. 
The  same  form  of  bacterial  infection  may  cause  a  slight  and  transitory 
inflammation,  suppuration,  or  gangrene.  Acute  suppuration  is  usually 
due  to  the  ordinary  pyogenic  organisms.  The  formation  of  cold  abscesses 
is  particularly  characteristic  of  the  tuberculous  and  the  post-typhoidal 
infections.  It  may,  however,  follow  an  attenuated  or  highly  resisted 
infection  by  the  ordinary  pyogenic  microorganisms. 

Fever. — Fever  associated  with  increase  in  pulse  and  respiratory  rate, 
headache,  loss  of  appetite,  lessened  peristalsis,  deficient  secretion  and 
excretion,  and  general  muscular  pain,  occurs  at  least  in  a  slight  degree 
after  all  severe  traumata.  It  is  an  almost  invariable  symptom  of  the  acute 
infections,  unless  they  be  of  overwhelming  and  shocking  intensity.     It 


INFLAMMATION 


69 


is  usual  in  chronic  infections,  and  is  frequently  observed   in  rapidly 
growing  neoplasms. 

Traumatic  Aseptic  Fever. — In  its  lightest  form  it  is  observed  after 
fractures  or  clean  wounds.  The  temperature  rises  in  the  first  twenty- 
four  hours  to  between  99°  and  101''.  Neither  the  pulse  nor  the  tempera- 
ture is   materially  affected,  nor  are   other  symptoms   of  malaise   pro- 

FiG.  18 


Carcinoma  of  stomach.  Partial  gastrectomy  and  gastro-enterostomy.  The  cliart  shows  the 
effect  of  shock  following  the  operation,  the  temperature  dropping  to  96°  and  the  pulse  rising 
to  120°. 

Fig.  19 


< 

a. 

CC 

TEMPERATURE  (fAHR.) 

97    98     99    ino 

2/27 

116 

26 

M 

1 

80 

24 

E 

■ 

~^-— =dj 

28 

82 

22 

M 

, - 

_ — Z-::^ 

80   2-1 

E 

^-^ 

3/1 

82 

22 

M 

^-^ 

80 

23 

E 

---^-l^ 

2 

74 

20 

M 

-"^ 

84 

24 

E 

\> 

3 

72 

20 

M 

/ 

84 

20 

E 

\,^ 

i 

84 

20 

M 

^^pffi 

96 

22 

E 

L>» 

5 

84 

24 

M 

___. — ■ 

96  1  24 

E 

1  ~~-~-^--__ 

Appendectomy.      Typical  traumatic  reactionary  fever. 

nounced.  Within  the  next  forty-eight  hours  the  fever  drops  to  about 
normal  unless  there  be  a  large  thrombus,  in  which  case  it  may  remain 
of  the  same  grade  for  three  or  four  days.  There  may  be  slight  leuko- 
cytosis, and  albumin  and  a  few  red  cells  may  be  found  in  the  urine. 
When  a  wound,  either  operative  or  otherwise,  has  been  attended  by  pro- 
found shock  the  temperature  rise  is  correspondingly  greater. 

This  form  of  fever,  due  to  the  absorption  of  devitalized  tissues  and 


70 


INFLAMMATION 


effused  blood,  at  times  partially  to  reaction  from  the  shock,  is  charac- 
terized by  its  transitory  nature,  its  tendency  toward  subsidence  rather 
than  increment  after  the  first  onset,  and  the  absence  of  associated  toxic 
symptoms.  At  the  seat  of  traumatism  there  is  swelling,  with  heat,  ten- 
derness, and  redness,  reaching  its  moderate  maximum  about  the  third 
day  and  thereafter  rapidly  subsiding. 


Fig.  20 


S 

TEMPERATURE  (fAHR.) 

97     98     99    inO 

12/19 

64 

22 

M 

i 

86 

22 

E 

1 

20 

84 

22 

M 

~p^ 

90 

26 

E 

\^ 

21 

80 

24 

M 

,„^-^ 

80 

22 

E 

22 

74 

20 

M 

72 

20 

E 

23 

72 

20 

M 

78 

20 

E 

"^^9 

24 

74 

20 

M 

c-^ 

78 

18 

E 

s» 

25 

74 

20 

M 

y^ 

76 

22 

E 

'■ i 

r 

Cholelithiasis.      Typical  moderate  traumatic  reaction. 
Fig.  21 


1- 

2 

S 

tt 

TEMPERATURE  (fAHR.) 

97    98     99    100    101 

2/9 

M 

102 

26 

E 

10 

78 

22 

M 

— 

, 



90 

22 

E 

*■ 

^^. 

11 

94 

20 

M 

.^^ 

84 

22 

E 

\, 

12 

96 

22 

M 

^-— ^ 

82 

22 

E 

^^ 

13 

84 

22 

M 

^-^ 

86 

22 

E 

s^ 

14 

96 

20 

M 

a*-" — 

■"^ 

90 

22 

E 

"^^ — 

— 

15 

96 

20 

M 

, 

,--^^^* 

90 

20 

E 

V 

16 

78 

20 

M 

^ — ' 

E 

Incarcerated  femoral  hernia.     Fever  continued  several  days  without  any  visible  evidence  of 
infection.    There  was,  however,  after  the  first  day  a  gradual  fall.     There  was  no  pulse  hurry. 

Septicemia. — Following  an  infected  wound,  there  may  develop  within 
the  first  twenty-four  hours  the  fever  characteristic  of  reaction.  Instead 
of  subsiding  on  the  second  or  third  day,  this  fever  becomes  more  pro- 
nounced, exhibiting  a  morning  remission  and  an  evening  rise.  It  is 
associated  with  headache,  general  muscular  pain,  distaste  for  food, 


INFLAMMATION 


71 


constipation,  and  high-colored,  scanty  urine  and  pronounced  leukocytosis. 
If  the  wound  has  been  properly  drained,  the  vital  resistance  high,  and  the 
infecting  organism  one  of  ordinary  virulence,  this  fever  reaches  its  maxi- 
mum on  the  third  or  the  fifth  day  and  then  gradually  subsides.  Under 
other  circumstances,  pus  under  tension,  virulent  infection,  or  low  resist- 


FiG.  22 


I 

13 

1 

TEMPERATURE  (fAHR.) 

97    98     99    100    101    102    103 

,/8 

90 

24 

M 

90 

22 

E 

' 

' 

9 

92 

22 

M 

S 

108 

28 

E 

10 

114 

28 

M 

'' 

106 

28 

E 

11 

106 

38 

M 

100 

28 

E 

12 

96 

36 

M 

Or ■ 

96 

34 

E 

% 

13 

94 

24 

M 

a ■ 

r"""^ 

84 

23 

E 

I 

U 

80 

23 

M 

^...-^ 

83 

22 

E 

X 

Retention  cyst  of  breast,  followed  after  excision  by  sloughing  of  a  portion  of  the  overlying 
skin.      Sudden  rise  in  temperature  and  gradual  daily  fall. 

Fig.  23 


Perforating  gastric  ulcer.  Convalescence  normal  until  fourteenth  day;  temperature  then  began 
to  rise.  The  chart  shows  an  unusual  temperature  jump  due  to  a  small  parietal  abscess.  Pulse 
but  slightly  affected.      Prompt  subsidence  of  symptoms  on  drainage. 

ance,  this  fever  continues,  ranging  from  101°  to  105°,  with  nocturnal, 
often  irregular  exacerbations,  the  latter  not  infrequently  accompanied 
by  a  chill,  and  being  suggestive  but  not  diagnostic  of  the  development 
of  other  suppurating  foci  through  the  medium  of  septic  emboli. 

If  the  systemic  reaction  against  the  infecting  agent  be  well  expressed, 
there  will  be  a  strong,  regular  pulse  proportionate  in  rapidity  to  the 


72 


INFLAMMATION 


degree  of  fever  and  pronounced  leukocytosis  (polymorphonuclear).  A 
pulse  disproportionately  rapid  as  compared  with  the  temperature  and 
slight  leukocytosis  are  suggestive  of  reactive  failure. 

A  long  continuance  of  acute  septicemia  is  impossible.     There  is  rapid 
emaciation,  profound  muscular  degeneration  indicated  by  the  increasingly 


Fig.  24 


< 

3 

ffi 

TEMPERATURE  (fAHR.) 

97    98     99    100    101    102 

2/22 

120 

24 

M 

, 

106 

24 

-E 



■ 

23 

106 

24 

M 

" 

1 

\^ 

120 

26 

E 

Jk-^ 

24 

116 

24 

M 

^^ 

— 

114 

26 

E 

*^ 

■ 

25 

92 

28 

M 



~~ 

" 

94 

24 

E 

■ 

^^_^ 

* 

26 

90 

25 

M 

,,~—^^ 

92 

26 

E 

■~— .^ 

27 

88 

24 

M 

^^_— 



98 

28 

E 

*^^~~ — -, 

r~— !=« 

28 

100 

24 

M 



r--^^ 

98 

24 

E 

*~~~ — ^ 

Perforated  appendix.      Immediate  postoperative  drop  in  temperature;  rise  in  reaction  plus 
continued  sepsis;  gradual  drop  from  drainage  and  elimination. 

Fig.  25 


0 

3 

3 

i 

TEMPERATURE  (fAHR.) 

97    98     99    100    101    102    103 

n/ii 

102 

28 

M 

106 

26 

E 

28 

104 

28 

M 

152 

48 

E 



29 

134 

40 

M 

118 

38 

E 



30 

130 

36 

M 

^/'^'"^ 

126 

32 

E 

^^^ 

12/1 

106 

32 

M 

^_^__.^ 

— '• — " 

110 

30 

£■ 

*'^^~--~-l 

-^.^ 

2 

106 

33 

M 

^__„^ 

-^^^^ 

104 

32 

E 

""^^^^^^ 

-•^=« 

3 

96 

30 

M 

^_,.-..-- 

-=^ 

112 

32 

E 

1 

■• 

Typhoid  perforation.     Immediate  postoperative  drop  in  temperature  and  rise  in  pulse  rate. 

rapid  and  feeble  heart  action,  pronounced  anemia,  and  scanty  and  per- 
verted secretions  and  excretions.  The  dry,  brown  tongue,  the  feeble 
muttering,  restless  delirium,  and  the  general  condition  of  adynamia  are 
characteristic. 

The  local  symptoms  of  increasing  infection  in  the  wound  are  more 
severe  pain  and  tenderness,  and  on  inspection  the  well-developed  phe- 
nomena of  acute  inflammation. 


INFLAMMATION  73 

A  mild  form  of  septicemia  may  continue  for  months,  characterized 
by  evening  rise  of  temperature,  often  night  sweats  and  rigors,  pulse 
hurry,  and  progressive  emaciation.  This  is  called  hectic  fever,  the  word 
hectic  meaning  habitual,  and  is  seen  typically  in  tuberculosis  with  mixed 
infection  and  inadequate  drainage,  as  of  the  lungs.  It  is  also  character- 
istic of  other  chronic  infections. 

Pyemia. — If  septic  thrombi  are  carried  into  the  general  circulation, 
metastatic  abscesses  will  form,  the  lungs,  spleen,  kidneys,  and  joints 
being  seats  of  predilection;  the  liver,  if  the  infecting  focus  lie  in  the 
area  drained  by  the  portal  vein. 

Paroxysms  of  chill,  fever,  and  sweat  are  habitual  in  this  condition 
and  may  recur  several  times  in  twenty-four  hours;  the  temperature  fluc- 
tuations are  from  97°  to  106°,  The  diagnosis  is  based  on  the  local 
symptoms  of  infection  in  regions  removed  from  the  primary  focus. 
Bronchopneumonia  characterized  by  hurried,  painful  respiration  cough, 
pleuritic  pain,  friction,  percussion  dulness,  and  the  usual  auscultatory 
sign  is  commonly  the  first  manifestation. 

The  particular  variety  of  microorganisms  which  causes  septicemia  or 
pyemia  is  determined  by  cultures  made  from  the  blood. 

Fever  of  the  acute  or  chronic  septic  type  is  common  to  both  medical 
and  surgical  affections;  before  deciding  that  it  is  purely  medical  an 
adequate  local  cause  should  be  searched  for.  If  the  fever  be  acute  and 
violent,  some  surgical  conditions  which  are  at  times  overlooked  should 
be  considered.  Among  the  more  important  of  these  are  osteomyelitis, 
otitis  media  and  its  complications  (especially  in  infants),  infections  of 
the  accessory  nasal  cavities,  and  septic  thrombosis  of  the  kidney.  Acute 
osteomyelitis  and  otitis  media  may  have  in  children  no  early,  readily 
elicited,  localizing  symptoms. 

Acute  ulcerative  endocarditis  is  in  itself  an  adequate  cause  for  violent 
sepsis,  though  it  is  very  commonly  a  complicating  factor. 

Even  though  a  wound  remains  sterile,  fever  of  such  height  may  develop 
as  to  suggest  the  presence  of  a  local  infection.  Two  common  causes  of 
such  fever  are  constipation  and  follicular  tonsillitis. 

Constipation  fever  is  characterized  by  a  rapid  rise  during  the  course 
of  an  apparently  smooth  convalescence,  with  an  associated  coated  tongue 
and  heavy  breath ;  usually  there  is  a  slight  headache,  with  a  history  of  no 
bowel  movement  for  two  or  three  days.  The  pulse  as  compared  with 
the  temperature  is  disproportionately  slow  (often  characteristic  of 
intestinal  toxemia),  nor  is  there  more  pain  referred  to  the  wound  than 
has  previously  been  experienced.  The  diagnosis  is  based  on  the 
prompt   subsidence  of  these  symptoms  when   the   bowels  are  moved. 

The  fever  of  follicular  tonsillitis  is  typical  of  acute  infection,  and  would 
suggest  a  hyperactive  bacterial  growth  in  the  wound  were  sore  throat 
and  the  red,  swollen,  spotted  tonsils  not  found. 

The  malarial  paroxysm  may  exactly  simulate  that  of  pyemia ;  the  com- 
plete and  regular  intermissions  and  the  comparatively  trifling  effect 
on  the  general  health  are  characteristic.  The  blood  examination  is 
diagnostic. 


74 


INFLAMMATION 


Complicating  septic  fevers  there  are  a  number  of  skin  eruptions, 
herpetic,  urticarial,  scarlatiniform,  or  petechial,  the  latter  of  serious 
moment. 

In  the  absence  of  an  obvious  focus  of  entrance  there  may  develop  a 
condition  of  chronic  sepsis  characterized,  not  so  much  by  fever,  though 
this  may  be  present  in  an  irregular  hectic  form,  as  by  deterioration  of 
general  health,  multiform  skin  lesions,  affections  of  the  joints  usually 
regarded  as  evidences  of  chronic  rheumatism,  loss  of  weight,  slight 
albuminuria,  and  gastro-intestinal  disturbances  incident  to  absence  or 
perversion  of  secretion  or  sluggish  peristalsis.  Blood  examination  may 
show  the  presence  and  the  nature  of  the  infecting  organisms.  When 
this  fails,  in  the  absence  of  organic  lesions  it  is  to  be  assumed  that  the 
symptoms  are  incident  to  a  toxic  absorption. 

Fig.  26 


^ 

c 

TEMPERATURE  (fAHR.) 

97     9S     99    100    101    102    103 

■/« 

80 

20 

M 

106 

24 

E 

c   . 

— - 



7 

lOi 

23 

M 

/* 

106 

24 

E 

— ^___ 

8 

130 

26 

M 

■ 

150 

28 

E 

» 

^ 

• 

9 

116 

28 

M 



108 

26 

E 

"~~~— -— 

.. 

10 

98 

22 

M 

^ 

_->® 

92 

22 

E 

""^^^ — 1 



11 

90 

22 

.  M 

ffl^'"^ 

86 

22 

E 

^^^>ii 

12 

84 

24 

M 

-■''^^ 

90 

22 

E 

"~^~.-,^ 

Vesical  calculi. 


Perineal  cystotomy.     Immediate  and  violent  sepsis, 
fall  in  temperature  and  pulse  rate. 


Characteristic  rapid 


To  this  form  of  hidden  infection  the  term  cryptogenic  has  been  applied. 
This  is  not  applicable  unless  the  nose  and  its  accessory  sinuses,  the 
teeth,  mouth,  throat,  especially  the  tonsils,  urethra,  prostate,  and  seminal 
vesicles,  and  the  anus  and  rectum  have  been  carefully  examined  for  signs 
of  chronic  infection.  The  common  sources  of  such  infection  or  toxemia 
which  are  not  subject  to  direct  examination  are  the  appendix,  gall 
bladder,  the  stomach  and  duodenum,  and  the  renal  pelvis. 

The  fever  symptomatic  of  a  cholangitis,  which  frequently  accompanies 
gallstones,  is  characterized  by  its  irregular  recurrences  and  its  marked 
fluctuations,  constituting,  when  depicted  in  graphic  form,  the  so-called 
steeple  chart. 

The  septicemia  which  accompanies  urethral  traumatism  is  character- 
ized by  its  sudden  onset  and  usually  equally  sudden  subsidence.  It  is 
commonly  expressed  in  the  form  of  a  single  paroxysm  which  may  occur 
in  an  hour  from  a  trauma  so  slight  as  that  incident  to  the  gentle  passage 
of  a  sound.     There  is  chill,  fever  which  may  go  as  high  as  106°,  and 


INFLAMMATION 


75 


headache,  often  without  corresponding  rise  in  the  pulse  rate.  It  may 
subside  completely  in  six  to  twenty-four  hours,  or  may  recur,  assuming 
then  the  features  of  an  acute  septicemia.  A  rapid  pulse  is  suggestive  of 
a  recurrence  of  such  attacks. 

Erysipelas  (Streptococcus). — Erysipelas,  exhibiting  a  predilection 
for  the  face,  is  often  initiated  by  chill,  fever,  and  vomiting,  and  the 
formation  of  a  red  patch,  with  distinct,  slightly  raised  borders,  which 
rapidly  invades  the  surrounding  skin,  is  usually  attended  with  moderate 
vesication  and  glandular  enlargement,  and  is  accompanied  by  the  con- 
stitutional symptoms  of  an  active  sepsis.  The  inflammation  is  most 
intense  at  the  borders  and  has  a  tendency  to  fade  in  the  centre. 


Fig.  27 


1- 
< 

3 

K 

TEMPERATURE  (fAHR.) 

98     99    100    101    102    103    104    105 

i/n 

82 

20 

M 

86 

24 

E 

■ 

. 

12 

100 

24 

M 

fif^^ 

122 

24 

E 

~ 

13 

98 

24 

M 

116 

24 

E 

" 

14 

94 

22 

M 

" 

108 

24 

E 

"     ■ 

15 

96 

20 

M 

«-=^ 

- 

114 

24 

E 

16 

90 

20 

M 



96 

20 

E 

~- — — . 

17 

84 

20 

M 

______ 

■ 

90 

22 

E 

■ , 

-~« 

Urinary  fistula  and  stricture.     Internal  urethrotomy;  urinary  sepsis  developing  eleven  days  after 
operation,  following  instrumentation  but  not  immediately;   duration  longer  than  usual. 


A  deeper  infection,  cellulitis,  is  characterized  by  more  profound  sepsis, 
a  dusky  rather  than  red  color  of  the  skin,  pitting  on  pressure,  ulti- 
mately bogginess  from  tissue  destruction  and  pus  formation,  and  the 
symptoms  of  at  first  a  violent,  then,  if  the  infection  be  progressive, 
an  overwhelming  sepsis.  This  is  the  form  of  infection  common  in  deep 
lacerated  and  contused  wounds. 

Abscess,  carbuncle,  and  erysipeloid  are  elsewhere  described. 

Tuberculous  Infection. — Tuberculous  infection,  against  which  none 
of  the  tissues  of  the  body  are  immune,  in  its  surgical  form  exhibits  a 
predilection  for  the  lymphatic  glands,  the  vertebral  bodies,  and  the 
growing  epiphyses  of  the  long  bones.  It  is  characterized  by  a  chronic 
inflammation  attended  by  few  symptoms  beyond  swelling  incident  to 
organization  of  exudate  and  destruction  of  tissue.  There  is  ultimately 
abscess  formation,  characterized  by  the  appearance  of  a  fluctuating 
tumor  without  other  local  symptoms  until,  by  pressure  necrosis  and 
skin  infection,  the  abscess  is  about  to  burst. 

The  diagnosis  of  the  tuberculous  nature  of  the  lesion  is  based  upon  its 
otherwise  inexplicable  occurrence,  its  chronic  course,  its  age  and  loca- 


76  INFLAMMATION 

tion,  incidence,  the  results  of  the  tubercuhn  test,  and  the  examination 
of  the  discharge.  Similar  chronic  inflammations  may  be  caused  by  a 
great  variety  of  infecting  organisms,  among  them  exceptionally  the 
staphylococcus  and  streptococcus. 

Actinomycosis. — Actinomycosis,  an  infection  due  to  the  Streptothrix 
actinomyces,  usually  develops  in  the  lower  jaw;  the  upper  jaw,  tongue, 
fauces,  lungs,  or  any  part  of  the  alimentary  tract,  especially  the  cecum 
and  the  liver,  may  be  the  primary  seat  of  infection. 

The  disease  is  characterized  by  dense  nodulation,  slow  extension,  a 
marked  tendency  to  fistulization,  and  the  discharge  of  pus  containing 
granules  in  which  the  infecting  organisms  may  be  identified.  It  spreads 
by  continuity  of  tissue,  is  slow  in  progress  (months,  years),  and,  in  the 
case  of  the  internal  organs,  is  usually  not  suspected  until  the  parietes  are 
infiltrated  and  the  sinuses  or  fistulas  form. 

The  distinction  from  tuberculosis  is  based  on  the  tendency  of  the  latter 
infection  to  invade  the  lymph  glands,  the  results  of  tuberculin  and 
laboratory  tests. 

Anthrax. — Anthrax,  observed  in  those  who  handle  the  hides,  or  the 
carcasses  of  animals  which  have  been  affected  by  the  disease,  develops 
on  an  exposed  surface  of  the  body  as  an  acutely  inflamed,  painful 
pimple,  which  becomes  densely  indurated  and  is  surrounded  by  a  cluster 
of  vesicles.  These  are  regarded  as  characteristic.  There  is  central 
sloughing  and  rapid  extension  of  induration  and  edema.  The  symp- 
toms are  those  of  acute  sepsis. 

Diagnosis  is  made  by  examination  of  the  blood,  of  the  wound  secre- 
tion, and  finally  by  the  excision  of  a  small  portion  of  the  area  of  active 
infection  and  the  examination  of  it  for  the  anthrax  bacillus.  From  car- 
buncle the  distinction  is  suggested  by  the  prompt  skin  necrosis  and  the 
rapid  extension  of  the  infection.  The  edematous  form  is  characterized 
by  a  widespread  swelling  and  multiple  sloughs. 

Tetanus. — Tetanus,  incident  to  the  toxic  action  of  the  bacillus  tetani 
and  particularly  likely  to  follow  punctured  and  lacerated  wounds  in- 
fected by  earth,  is  characterized  at  first  by  stiffness  of  the  jaw  and 
neck  of  such  slight  degree  that  the  patient  may  give  it  little  atten- 
tion. If  the  wound  has  involved  the  hand  or  foot,  the  corresponding 
extremity  may  first  exhibit  muscular  stiffness.  There  follow  fixation 
of  the  jaw,  rigid  extension  of  the  head  and  tonic  spasm,  the  latter 
accompanied  by  clonic  exacerbations,  distorting  the  body  and  caus- 
ing asphyxia,  which  may  be  fatal  in  its  completeness  and  prolonga- 
tion. The  rapid  progression  and  violence  of  the  symptoms  is  usually 
inversely  proportionate  to  the  period  of  incubation,  those  developing 
within  a  week  of  the  wound  usually  ending  fatally.  A  prolonged  incu- 
bation, two  weeks  or  more,  is  often  followed  by  spasm  less  frequent 
and  less  violent,  with  almost  complete  muscular  relaxation  during  the 
interval. 

There  is  a  form  of  tetanus  occurring  after  infected  head  wounds  char- 
acterized by  unilateral  facial  palsy  and  spasm  limited  mainly  to  the 
muscles  of  the  head  and  neck. 


INFLAMMATION  77 

The  diagnosis  of  tetanus  is  based  upon  the  presence  of  an  infected 
wound,  the  development  of  the  characteristic  symptoms,  and  often  upon 
finding  the  specific  bacilhis  in  the  wound. 

Hydrophobia,  or  Rabies. — Hydrophobia  incident  to  the  bite  of  a 
rabid  dog,  wolf,  or  other  animal  and  occurring  after  an  incubation  period 
which  should  average  forty  days  is  characterized  first  by  depression, 
restlessness,  and  apprehension,  and  often  by  pain  or  hypersensitiveness 
in  the  region  of  the  wound.  Thereafter  follow  for  some  days  stiff  neck 
and  difficult  deglutition,  with  the  development  of  spasm  confined  to  the 
neck  and  jaw  muscles,  and  brought  on  or  aggravated  by  efforts  at  swal- 
lowing. Hallucinations,  delirium,  recurring  throat  spasm,  and  finally  an 
ascending  palsy  are  the  characteristic  features  of  the  affection.  It  is 
distinguished  from  tetanus  by  the  difference  in  etiology  and  by  the 
general  spasms  of  the  latter  condition,  which  especially  involve  the 
muscles  of  respiration.  Moreover,  tetanus  in  its  virulent  form  has  a 
short  incubation  period. 

When  a  psychic  hydrophobia  attacks  one  not  familiar  with  the  true 
symptomatology  of  the  infection,  it  is  characterized  by  an  incubation 
period  too  brief  to  be  real  and  the  sudden  onset  of  symptoms  correspond- 
ing in  type  with  the  popular  impression  of  the  disease  rather  than  its 
terrible  reality. 

Glanders. — Glanders,  an  infection  by  the  Bacillus  mallei,  observed 
in  those  who  handle  horses  or  other  aquidse,  is  characterized  by  a  pre- 
liminary typhoidal  state  with  discharge  from  the  nose,  the  symptoms  of 
bronchopneumonia  of  slight  or  moderate  severity,  and  the  development 
of  multiple  hard  swellings  in  the  skin,  beneath  it,  or  in  the  muscles, 
which  soften  and  break  down,  discharging  a  bloody  pus.  The  consti- 
tutional symptoms  are  those  of  an  active  and  progressive  sepsis.  The 
diagnosis  is  based  on  finding  the  specific  bacillus  in  the  discharge  of 
the  lesions.  It  is  suggested  by  the  usual  occupation  of  those  suffering 
from  this  infection,  but  is  usually  not  suspected  until  the  skin  nodules 
appear. 

If  the  inoculation  be  through  a  skin  abrasion  or  wound,  this  becomes 
converted  into  a  destructive  ulcer,  usually  of  small  size,  with  lymphatic 
involvement.  The  red  skin  nodules  constituting  the  farcy  buds  appear 
later. 


CHAPTER    IV. 

COMPLICATIONS  AND  SEQUELS  OF  TRAUMA. 

Shock. — Shock,  a  condition  of  vasomotor  paresis,  mainly  incident 
to  trauma,  often  accentuated  by  the  psychic  state,  is  characterized  by 
pallor,  subnormal  temperature,  muscular  relaxation,  shallow,  irregular 
•breathing,  often  hurried  in  rhythm  and  interrupted  by  long  deep  breaths, 
low  blood  pressure,  and  a  running  pulse.  The  mentality  is  lethargic, 
the  skin  moist,  the  face  expressionless,  the  pupils  moderately  dilated; 
nausea,  vomiting,  and  incontinence  of  urine  are  often  present.  There 
is  an  erethistic  form  characterized  by  uncontrollable  restlessness  and 
delirium. 

Shock  is  especially  pronounced  in  burns,  acute  perforation  of  the 
stomach  with  rapid  escape  of  contents,  acute  hemorrhagic  pancreatitis, 
and  injury  to  the  central  nervous  system.  In  peripheral  crushes  it  is 
usually  proportionate  to  the  amount  of  tissue  involved.  There  is  an 
extraordinary  individual  variation  of  susceptibility  to  this  condition. 

The  shock  of  operation  is  usually  proportionate  to  the  duration  of 
exposure,  extent  of  traumatism,  and  particularly  the  quantity  of  blood 
lost. 

The  sudden  death  which  occurs  in  consequence  of  testicular  injury, 
incarcerated  or  strangulated  hernia  or  efforts  at  its  reduction,  tapping 
of  pleural  exudates,  or  the  passing  of  a  stomach  tube,  is  probably  due 
to  cardiac  inhibition. 

Hemorrhage. — ^Hemorrhage  is  characterized  by  rapid,  feeble  pulse, 
irregular,  shallow  respirations,  with  recurring  deep  sighing  inspiratory 
effort,  pallor,  sweating  skin,  blanched  lips,  air  hunger,  thirst,  often 
uncontrollable  restlessness,  failing  vision,  tinnitus,  unconsciousness,  and 
convulsions.  The  symptoms  are  those  of  shock;  the  two  conditions  are 
often  associated.  The  diagnosis  is  dependent  upon  the  history;  in 
case  of  internal  bleeding,  by  the  progressive  severity  of  symptoms  in  the 
absence  of  adequate  cause,  and  the  demonstration  of  a  fluid  effusion 
into  the  peritoneal  or  the  pleural  sac  or  into  the  gastro-intestinal  canal, 
as  shown  by  vomited  blood  or  that  passed  per  rectum. 

Postoperative  Vomiting. — Postoperative  vomiting  may  be  absent, 
slight  and  transitory,  or  persistently  recurring,  usually  exhibiting  a 
definite  relation  in  its  severity  to  the  skill  of  the  etherizer.  When  the 
patient  has  been  properly  prepared  the  vomitus  is  of  glairy  mucus,  not 
infrequently  containing  streaks  of  blood  from  the  throat,  and  smelling 
strongly  of  ether.  Later  there  is  a  bile  admixture.  In  the  course  of  the 
first  twelve  hours  this  vomiting  practically  should  cease.  When  it  is 
prolonged  for  more  than  twenty-four  houjrs,  and  particularly  when  it  is 


COMPLICATIONS  AND  SEQUELS  OF  TRAUMA  79 

frequently  recurring  it  is  symptomatic  of  either  deficient  hepatic  met- 
abolism (acidosis)  or  renal  elimination,  or,  if  an  abdominal  operation  has 
been  performed,  it  suggests  acute  gastric  dilatation  or  mechanical  or 
dynamic  ileus. 

Defective  liver  metabolism  is  evidenced  by  the  presence  of  acetone 
and  diacetic  acid  in  the  urine.  In  its  more  pronounced  form  coma 
develops.  In  this  relation  it  is  worthy  of  note  that  a  latent  diabetes  may 
be  made  active  by  operative  procedure  and  may  cause  fatal  coma  even 
though  the  wound  run  a  clean  course. 

The  vomiting  of  ileus  or  acute  gastric  dilatation  is  accompanied  by 
the  characteristic  symptoms  of  these  conditions.  It  is  usually  regur- 
gitant in  type,  and  is  profuse,  offensive,  and  brown  in  color. 

Pressure  palsies  are  first  observed  when  the  patient  recovers  from 
ether.  The  brachial  plexus  or  some  of  its  branches  are  commonly  in- 
volved, usually  due  in  the  former  case  to  prolonged  Trendelenburg 
position,  with  the  forearm  hanging  above  the  head  (pressure  of  the 
clavicle),  in  the  latter  to  resting  the  arm  on  the  edge  of  the  table  (ulnar, 
musculospiral). 

Postoperative  Complications  of  Celiotomy. — Some  complications 
are  peculiar  to  abdominal  operations,  others  follow  them  more  frequently 
than  they  do  operations  on  other  portions  of  the  body. 

In  the  first  twenty-four  hours  after  celiotomy  there  is  always  local,  at 
times  general  atony,  characterized  by  feeble  peristalsis,  general  tympany, 
and  pain  and  tenderness  incident  to  the  peritoneal  reaction  against  trau- 
matism; the  pulse  is  not  markedly  affected.  This  condition  is  usually 
transitory,  audible  peristalsis,  colicky  pain,  and  the  passage  of  flatus, 
denoting  the  return  of  intestinal  tonus  on  the  second  or  third  day. 

Exceptionally  immediately  after  operation,  and  as  the  result  of  rough 
manipulation,  prolonged  exposure,  and  inadequate  preparation,  the 
gastro-intestinal  atony  is  associated  with  a  distention  so  great  as  to  con- 
stitute dynamic  ileus  (p.  481).  Ether  vomiting  is  succeeded  by  that 
characteristic  of  ileus,  the  pulse  becomes  rapid  and  feeble,  and  the 
breathing  hampered  by  upward  pressure  against  the  diaphragm.  Neither 
the  severe  pain,  great  tenderness,  nor  muscular  rigidity  of  diffuse  perito- 
nitis are  present. 

Dynamic  ileus,  developing  on  the  second  or  third  day  after  operation, 
is  usually  incident  to  diffuse  peritoneal  infection. 

Acute  gastric  dilatation,  a  local  form  of  dynamic  ileus,  coming  on 
immediately  after  operation  or  days  later  can  be  recognized  as  such 
only  in  the  early  stages  when  the  tympany  is  mainly  epigastric  and 
peristalsis  not  yet  abolished,  unless  the  great  relief  obtained  by  gastric 
lavage  can  be  considered  characteristic. 

Postoperative  diffuse  peritonitis  is  characterized  by  a  steady  increase 
in  postoperative  pain,  a  progressive  rise  in  the  pulse  rate,  a  temperature 
higher  than  that  characteristic  of  normal  wound  reaction  and  the  tender- 
ness and  muscular  rigidity  of  peritonitis  associated  with  absent  peristalsis, 
tympany,  regurgitant  vomiting,  and  absolute  constipation  (p.  482). 
Postoperative   mechanical   obstruction   and    strangulation    exhibit  the 


80  COMPLICATIOES  AND  SEQUELS  OF  TRAUMA 

symptoms  of  these  conditions  as  they  occur  in  the  absence  of  operation 
(p.  482). 

Postoperative  phlebitis,  probably  an  expression  of  mild  infection, 
develops  in  the  second  week  after  abdominal  section,  and  involves 
most  frequently  the  left  femoral  and  the  long  saphenous  vein.  Pain, 
fever,  and  leukocytosis  are  accompanied  or  followed  by  the  detection  of 
a  tender  indurated  cord  occupying  the  position  of  the  vein.  Throm- 
bosis and  phlebitis  of  intra-abdominal  veins  can  be  recognized  only  by 
exclusion. 

Pneumonia  is  comparatively  rare  when  the  anesthesia  is  intrusted 
to  skilful  hands  and  the  after  treatment  of  patients  is  conducted  in 
rooms  and  wards  in  which  pneumonia  cases  are  not  treated,  except  in 
its  embolic  form,  and  is  characterized  by  moderate  fever  and  pulse  hurry, 
rapid  breathing,  localized  signs  of  consolidation,  and  at  times  slightly 
blood-stained  expectoration.  When  lobar  or  lobular,  it  conforms  to 
type.  Pneumonia,  bronchitis,  and  pleurisy  are  observed  more  frequently 
after  abdominal  than  after  other  operations  even  when  local  anesthesia 
is  used. 

Parotitis,  characterized  by  local  swelling,  tenderness,  and  pain,  is 
more  frequent  after  abdominal  operations,  particularly  those  involving 
the  pelvic  organs,  than  after  peripheral  ones.  It  may  be  chronically 
inflammatory  in  type  or  acutely  suppurative  (p.  302). 

Hematemesis  is  an  expression  of  profound  blood  dyscrasia,  rare  as  a 
postoperative  complication,  but  less  so  after  operation  in  the  upper 
abdominal  segment  than  after  intervention  in  other  regions.  It  follows 
the  usual  postanesthesia  vomiting  immediately,  after  a  short  interval,  or 
not  for  days ;  it  is  regurgitant  in  type,  black  and  acid,  not  very  profuse, 
and  is  attended  by  the  constitutional  symptoms  and  the  facies  of  pros- 
trating toxemia.  It  may  be  associated  with  blood  in  the  stools  and 
subcutaneous  bleedings. 

Sudden  Death  Occurring  after  Operation. — Aside  from  death 
due  to  shock,  hemorrhage,  sepsis,  colossal  pulmonary  thrombosis,  fat 
embolus  (p.  97),  myocarditis,  acute  dilatation  of  the  heart,  uremia, 
acute  fatty  degeneration,  and  a  few  other  well-recognized  conditions 
with  fairly  characteristic  symptomatology,  there  remain  to  be  explained 
certain  fatalities  which  occur  suddenly  in  the  midst  of  an  apparently 
smooth  convalescence  and  with  premonitory  symptoms  entirely  wanting. 
Death  may  be  incident  to  a  sudden  change  in  posture  or  muscular  effort, 
and  may  be  preceded  by  only  a  few  seconds  of  agony.  In  such  cases 
colossal  pulmonary  embolus  or  the  final  overwhelming  of  a  dilated  heart 
are  regarded  as  adequate  causes,  as  they  are,  though  pulmonary  embolus  is 
not  immediate  in  its  effect  and  a  myocarditis  with  dilatation  and  impend- 
ing breakdown  should  have  given  warning  symptoms.  At  autopsy 
neither  of  these  conditions,  nor  coronary  embolus,  nor  adequate  heart 
lesion,  nor  bulbar  thrombus  has  been  found. 

Death  may  occur  during  sleep  without  change  in  posture  or  other  sign 
aside  from  respiratory  arrest.  In  the  case  of  one  patient  convalescent 
from  sunstroke  and  sleeping  quietly,  with  normal  pulse  and  tempera- 


COMPLICATIONS  AND  SEQUELS  OF  TRAUMA  81 

ture,  the  death  pallor  was  seen  to  sweep  over  his  face,  the  respiration  and 
the  heart  stopping  apparently  at  the  same  moment.  In  this  case  a  small 
clot  was  found  in  the  wall  of  the  fourth  ventricle. 

In  some  cases  such  an  apparently  causeless  death  seems  to  be  asso- 
ciated with  the  condition  termed  status  lymphaticus,  characterized  by 
enlargement  of  all  the  lymphatics  and  the  thymus  gland  and  a  general 
fiaccidity  of  tissue,  though  the  fatality  in  this  condition  is  more  likely  to 
occur  during  the  administration  of  an  anesthetic,  particularly  if  this  be 
chloroform. 

Iodoform  Poisoning. — Iodoform  poisoning  in  its  acute  form,  char- 
acterized by  a  fatty  degeneration  of  the  heart,  liver,  and  kidneys,  and  at 
times  edema  of  the  brain,  is  characterized  by  irregular,  rapid,  feeble  pulse, 
nausea  and  vomiting,  or  at  least  absolute  distaste  for  food,  headache, 
sleeplessness  and  psychical  depression,  or  even  active  delirium.  In  severe 
cases  coma  may  develop.  This  sometimes  may  follow  shortly  after  the 
first  dressing  or  injection,  or  may  be  delayed  some  weeks,  developing  only 
after  repeated  applications  of  the  drug.  Where  this  has  been  used 
judiciously  the  appearance  of  toxic  symptoms  must  be  attributed  to  an 
idiosyncrasy. 

The  diagnosis  should  be  based  on  the  apparently  causeless  circulatory 
failure,  associated  with  cerebral  symptoms,  and  upon  the  fact  of  absorp- 
tion as  attested  by  the  presence  of  iodine  in  the  urine.  The  diagnosis  is 
usually  confirmed  by  the  beneficial  effect  of  withdrawing  the  drug  as  a 
dressing,  though  the  systemic  improvement  may  be  slow.  Chronic 
poisoning  may  be  manifested  by  wasting,  complete  distaste  for  food  and 
symptoms  of  acute  poisoning  expressed  in  a  mild  form,  the  characteristic 
feature,  however,  being  persistently  rapid  pulse. 

Mercurial  Poisoning.  —  Mercurial  poisoning  is  characterized  by 
salivation,  vomiting,  bloody  diarrhea,  and  blood  and  albumin  in  the 
urine.     The  examination  of  the  urine  will  show  the  presence  of  mercury. 


CHAPTEK    Y. 

TUMORS.  « 

Tumor,  by  which  is  meant  a  functionless  independently  growing 
tissue  hyperplasia,  may  be  generally  classed  under  the  headings  benign 
and  malignant. 

The  benign  tumors,  at  times  multiple  in  their  beginning,  are  usually 
of  slow  growth,  are  characterized  by  the  presence  of  an  investing  capsule, 
the  absence  of  lymphatic  involvement,  failure  to  recur  after  complete 
removal  and  are  innocent  of  hurtful  effect,  except  that  of  mechanical 
pressure  incident  to  their  position. 

Malignant  tumors,  rarely  multiple  in  their  beginning,  are  usually  of 
rapid  growth,  are  characterized  by  the  absence  of  distinct  capsules,  a 
tendency  to  infiltrate  the  surrounding  tissues,  to  involve  the  anatomi- 
cally associated  lymph  glands,  to  recur  after  complete  removal,  and  to 
become  disseminated  through  the  system  by  either  the  lymphatic  or  the 
blood  channels.     They  are  ultimately  lethal. 

Rapid  growth  of  an  obviously  benign  cyst  or  tumor,  if  not  adequately 
accounted  for  by  trauma  or  inflammation,  should  be  regarded  as  sugges- 
tive of  malignant  transformation. 

The  general  symptoms  of  tumor  independent  of  its  benign  or  malig- 
nant nature  are  those  of  pressure  and  the  formation  of  a  mass.  In  the 
early  stages  of  growth  neither  skilled  palpation  nor  long  experience  can 
always  determine  whether  this  mass  is  benign  or  malignant.  When  the 
diagnosis  is  certain  because  of  infiltrations,  glandular  involvement, 
and  metastases,  the  time  for  intervention  has  passed.  It  would,  therefore, 
seem  logical  to  diagnosticate  all  tumors  which  are  not  obviously  benign, 
which  are  small  and  progressively  increasing  in  size,  and  have  recently 
developed,  by  wide  removal  and  microscopic  examination. 

Tumors  which  have  existed  for  years  without  marked  change  in  size, 
without  metastasis,  or  influence  on  general  health,  are  obviously  benign. 
Superficial  lipomata  and  angiomata,  multiple  osteomata  and  osteochon- 
dromata  of  the  growing  period,  papillomata  and  certain  of  the  fibromata, 
adenomata,  dermoids,  and  many  of  the  cysts  present  features  so  typical 
that  they  can  be  recognized  at  once  as  benign.  Any  of  these  tumors 
may  undergo  malignant  degeneration,  first  evidenced  by  rapid  growth. 
The  diagnosis  under  such  circumstances,  if  inflammatory  and  traumatic 
causes  be  excluded,  should  be  made  by  wide  excision. 

If  the  infections  can  be  excluded,  particularly  the  syphilitic  and  the 
tuberculous,  all  persistent  and  apparently  causeless  ulcerations  of  the  skin 
or  of  the  accessible  mucous  membranes  occurring  in  an  otherwise  fairly 
healthy  person  should  be  diagnosticated  in  the  early  period  of  their  devel- 


TUMORS  83 

opment  by  wide  excision  and  microscopic  examination.  From  this 
general  rule  leg  ulcers  and  those  which  are  prevented  from  healing  by 
lack  of  cleanliness  and  recurring  irritation  should  be  excluded. 

This  same  rule  in  regard  to  diagnosis  by  early  excision  holds  true  in 
regard  to  tumors  of  the  muscle  and  tendons  and  to  those  of  the  bone. 
In  the  latter  case  the  early  symptoms  are  expressed  in  the  form  of  pain. 
If  this  be  persistent,  well  localized,  increasing  in  severity  and  without 
apparent  cause,  and,  if  the  x-rays  show  a  circumscribed  area  of  rarefaction 
or  absorption,  the  diagnosis  should  be  made  by  exploratory  operation. 

Tumors  of  the  intra-abdominal  organs  have  usually  reached  such 
size  before  they  can  be  detected  by  palpation  or  can  be  suspected  from 
obstructive  or  pressure  symptoms  that,  if  malignant,  the  favorable  time 
for  intervention  has  passed. 


CHAPTER    VI. 

THE  SKIN. 

BuLKLEY,  in  an  analysis  of  20,000  cases  of  skin  diseases,  notes  that 
the  commonest  affection  is  eczema,  about  30  per  cent.  Next  in  order 
of  frequency  comes  acne,  16  per  cent.  Next,  syphilis,  12  per  cent.  It 
follows  that  nearly  two-thirds  of  all  patients  who  present  themselves  with 
skin  lesions  are  affected  with  one  of  these  three  diseases.  Psoriasis, 
the  eruptions  due  to  phytoparasites  (tinea),  zooparasites  (pediculus, 
acarus,  etc.),  and  urticaria  come  next  in  order  of  frequency. 

Fig.   28 


Acne  vulgaris.    (Hartzell.) 


Eczema. — Eczema  is  the  term  applied  to  a  chi-onic  skin  inflammation 
of  unknown  etiology  which  is  characterized  by  infiltration,  usually 
exudation,  exhibits  a  tendency  to  persist  or  recur,  and  is  attended  by 
itching  and  burning.     It  may  appear  in  the  erythematous,  papular, 


PLATE   IV 


Papular  and   Papulopustular    Syphilides. 

Early  secondary  (months).      No  subjective  symptoms.     Patient  feeling  well. 


PLATE  V 


Early  (Months)   Secondary  Syphilides. 

Eruption  universal.     Lesions  macular,  papular,  and  papulopustular.     Coppery  red,  neither  painful 
nor  itching.     Patient  feeling  well. 


Tff  E"  SKIN 


85 


vesicular,  or  pustular  form.  It  exhibits  remissions,  intermissions, 
relapses,  and  exacerbations  without  apparent  cause,  is  not  ulcerative  or 
destructive  in  its  tendency,  and  often  is  closely  related  to  gastro- 
intestinal disturbances  and  error  in  diet. 

Acne. — ^Acne  (pimples),  a  chronic  inflammation  of  the  sebaceous  glands 
and  the  periglandular  tissue,  occurring  during  adolescence  and  affecting 
by  preference  the  face,  back,  and  chest,  is  characterized  by  the  appearance 
of  usually  multiple  red  papules,  nodules,  or  pustules.  There  are  few 
subjective  symptoms.  The  individual  papules  may  often  show  the 
black  centres  characteristic  of  comedones,  and  the  latter  are  usually 
abundantly  distributed  over  the  surfaces  involved. 

The  black  point  of  the  comedo  represents  the  dried  secretion  of  a 
sebaceous  gland. 


Fig.    29 


Gumma  of  back.     Duration,  months.  No  subjective  symptoms. 


Syphilitic  Skin  Lesions. — The  manifestations  of  the  secondary  stage 
of  syphilis  are  widespread,  superficial,  non-destructive,  polymorphous, 
rounded  in  shape,  slightly  desquamative,  raw-ham  colored,  without 
subjective  symptoms,  and  exhibit  either  the  history  of  a  primary  lesion 
or  the  scar  and  often  the  glandular  involvement  of  its  one-time  presence. 
An  examination  of  the  serum  obtained  by  attrition  and  cupping  of  these 
lesions  will  show  the  presence  of  the  spirochete.  Destructive  lesions 
occurring  early  are  characteristic  of  a  virulent  infection. 

Tertiary  lesions,  single,  grouped,  or  symmetrically  disposed,  appear 
as  painless,  infiltrating,  rounded,  coppery  red  lesions  which  exhibit  a 


86 


THE  SKIN 


tendency  to  ulcerate  and  which  leave  permanent  pigmentation  and  scars. 
When  the  individual  lesions  become  confluent  the  resultant  ulcer  exhibits 
circinate  borders  often  with  central  healing  and  scar  formation.  If 
glandular  involvement  occurs,  this  is  incident  to  mixed  infection.  The 
diagnosis  strongly  suggested  by  the  indolent,  painless,  rounded  lesions 
is  corroborated  by  the  history  and  by  the  clinical  test  for  syphilis. 

Psoriasis. — Psoriasis  is  characterized  by  the  development  of  rounded, 
distinctly  defined,  slightly  elevated,  red,  non-ulcerating  papules,  often 
symmetrically  distributed  on  the  two  sides  of  the  body  and  exhibiting  a 
preference  for  the  extensor  surfaces  of  the  elbows  and  knees.     These 


Fig.  30 


Typical  cicatrix  of  tertiary  skin  lesions.     Soft,  irregularly  pigment  non-adlierent  scar, 
with  rounded  outlines  of  the  original  grouped  lesions. 

papules  exhibit  no  tendency  toward  ulceration,  but  are  often  covered  by 
an  imbricated  crust  of  silvery  white  epithelial  scales.  The  individual 
lesions  vary  from  the  size  of  pinheads  to  that  of  a  half-dollar,  and  by 
coalescence  may  form  irregular  patches.  The  condition  is  an  extremely 
chronic  one.  The  exfoliation  is  a  characteristic  feature.  The  distinc- 
tion from  syphilis  must  at  times  be  based  on  the  history  and  the  results 
of  specific  treatment. 

Of  the  phytoparasitic  eruptions,  tinea  favosa,  tinea  trichophytina, 
tinea  versicolor,  and  erythrasma  are  the  forms  commonly  encountered. 

Tinea  Favosa. — ^Tinea  favosa,  a  contagious  affection  commonest  in 
infancy  and  childhood,  is  characterized  by  the  formation  of  thick,  yellow- 
ish, brittle  crusts  of  mouse-like  odor,  occurring  in  rounded  or  irregular 


THE  SKIN 


87 


patches  upon  the  scalp.  The  hair  of  the  involved  region  is  brittle, 
stubbed,  broken,  and  exfoliated.  The  crusts,  when  not  disturbed,  exhibit 
a  characteristic  cupping. 

Diagnosis  is  based  on  the  finding  of  the  Achorion  schonleinii. 

Tinea  Circinata  (Ringworm). — ^Tinea  circinata,  as  it  occurs  upon  the 
body,  forms  usually  typical  red  annular  lesions,  M^hich  begin  as  small 
papules.  At  times  concentric  rings  are  observed  and  sometimes  vesicu- 
lation.  Even  if  the  circle  be  broken  the  outline  is  generally  crescentic. 
The  diagnosis  is  based  on  the  finding  of  the  Trichophyton  tonsurans. 


Fig.  31 


Tinea  favosa  (scalp). 


Tinea  Tonsurans. — Tinea  tonsurans,  the  expression  of  scalp  invasion 
by  the  same  parasite,  appears  in  the  form  of  rounded  scaling  skin  patches, 
in  which  the  hair  is  stubbed,  broken,  and  exfoliating.  The  diagnosis  is 
made  by  finding  the  parasite. 

Exceptionally  tinea  tonsurans  may  cause  a  distinct  boggy  scalp 
tumor  made  up  of  multiple  small  abscesses  exuding  a  gummy  secretion. 

Tinea  Sycosis. — Parasitic  sycosis,  due  to  the  same  infecting  agent  but 
appearing  upon  the  bearded  face,  is  characterized  at  first  by  small 
erythematous  or  edematous  rings  and  brittle  broken  hairs  and  stubs. 


88 


THE  SKIN 
Fig.   32 


Tinea  circinata.     Fungus  demonstrated.      (Hartzell.) 


Fig.  33 


Tinea  cruris.     (Hartzell.") 


THE  SKIN 


89 


Later,  by  a  diffused  skin  inflammation,  exliibiting  papules  and  pustules 
and  discharging  a  sticky  purulent  exudate  which  crusts. 

The  distinction  from  non-parasitic  sycosis  is  made  l)y  finding  the 
Trichophyton  tonsurans. 

Tinea  Versicolor. — ^Tinea  versicolor  appears  in  the  form  of  extensive 
patches  of  pigmented,  slightly  scaling  skin,  usually  on  the  anterior  sur- 
face of  the  chest,  sometimes  involving  the  greater  portion  of  the  surface. 


Fui.  34 


Tinea  tonsurans  (negi 


which  is  protected  by  the  clothing.  Pigmentation  is  the  only  feature 
which  attracts  attention.  The  diagnosis  is  made  by  finding  the  Micro- 
sporon  furfur. 

Erythrasma. — Erythrasma  is  the  term  applied  to  a  hyperemic  discolora- 
tion appearing  in  the  form  of  red  or  brownish  patches  on  surfaces  sub- 
ject to  prolonged  skin  contact  and  slight  friction,  such  as  the  gluteal 
fold,  about  the  axilla,  beneath  the  breast,  and  on  the  inner  upper  surface 
of  the  thigh.  The  diagnosis  is  based  on  finding  the  Microsporon  minu- 
tissimum. 

Pediculi. — Pediculi  may  cause  lesions  varying  from  a  slight  erythema- 
tous patch,  with  a  punctate  centre,  to  multiple  superficial  pustulization 
with  the  formation  of  thick  crusts. 


90 


THE  SKIN 


The  diagnosis  of  the  presence  of  the  head  louse  is  made  by  finding 
the  nits  glued  to  the  hair  in  the  area  of  preference,  i.  e.,  the  occipital  region. 

Body  lice  are  always  indicated  by  the  excoriations  of  universal  scratch- 
ing, usually  associated  with  minute  red  points  indicating  recent  puncture. 

Pubic  lice  lead  to  violent  itching  in  the  pubic  region,  and  the  lesions 
of  scratching,  which  are  to  be  seen  on  inspection,  together  with  the 
nits  attached  to  the  hairs. 


Fig.   35 


Tinea  sycosis.     (Hartzell.) 


Scabies,  or  Itch. — Itch  appears  as  a  papulopustular  eruption,  most 
pronounced  in  the  interdigital  folds,  the  axilla,  and  on  the  wrists,  thighs, 
and  abdomen.  It  is  attended  by  intense  itching,  particularly  at  night, 
and  often  out  of  proportion  to  the  extent  of  the  lesion.  Diagnosis  is  assured 
on  finding  in  an  unscratched  region  a  characteristic  tunnel  and  made 
absolute  by  extracting  the  Sarcoptes  scabiei  therefrom  with  a  fine  needle. 

Urticaria. — Urticaria,  often  accompanied  by  fever,  is  characterized  by 
the  sudden  or  rapid  development  of  small  or  large  burning  or  itching 
wheals,  which  may  disappear  as  rapidly  as  they  come. 

Closely  associated  with  this  condition  is  angioneurotic  edema,  in  which 
circumscribed  soft  swellings  are  produced  either  in  the  form  of  nodes 
on  the  surface  or  edematous  infiltration  of  regions  such  as  the  lip,  the  eye- 


THE  SKIN  91 

lid,  the  glottis,  or  internal  organs.  Such  an  edema  may  be  attended  by  a 
rapidly  developing  and  dangerous  asphyxia.  Its  internal  manifestations 
are  sometimes  evidenced  by  typical  symptoms  of  acute  intestinal  obstruc- 
tion (p.  481).  It  is  not  infrequently  associated  with  purpuric  eruption 
and  with  the  joint  manifestations  commonly  regarded  as  rheumatic. 

The  affections  of  the  sweat  glands  characterized  by  excess,  deficiency, 
or  perversion  of  secretion  are  sufficiently  obvious. 

Miliaria,  or  prickly  heat,  usually  associated  with  hyperactivity  of  the 
sweat  glands,  is  characterized  by  the  development  of  a  multitude  of 
minute  vesicles  upon  a  reddened,  stinging,  burning  skin. 

Cysts  of  the  coil  duct  occasionally  appear  upon  the  surface,  usually 
of  the  face  and  nose,  in  the  form  of  non-inflammatory,  tense,  round, 
translucent  vesicles. 

Fig.  36 


Itch.      (Hartzell.) 

Disorders  of  the  sebaceous  glands  are  usually  expressed  in  the  form 
of  seborrhea,  acne,  or  comedone. 

Seborrhea. — Seborrhea,  exhibiting  a  preference  for  the  scalp,  face,  and 
genital  regions,  may  appear  either  as  an  oily  exudate  or  more  commonly 
as  a  greasy  scaling  which  sheds  freely.  The  distinction  from  tinea,  when 
it  appears  in  patches  with  slight  inflammatory  symptoms,  is  made  by  the 
microscope. 

Milium,  common  in  infants  and  presenting  the  appearance  of  minute 
white  skin-embedded  seeds  (p.  260)  and  wens  (p.  240),  are  described 
elsewhere. 

Erythematous  skin  lesions  are  common  manifestations  of  toxemia 
and  infection.  They  develop  rapidly  as  irregularly  shaped  red  patches, 
often  of  large  size.  The  eruption  may  closely  resemble  that  of  scarlet 
fever,  but  is  unattended  by  the  pronounced  throat  symptoms,  and  des- 
quamation begins  in  a  few  days. 

Herpes  (p.  259),  erysipelas  (p.  75),  erysipeloid  (p.  360),  furuncle 
(pp.  245,  360),  carbuncle  (p.  245),  and  anthrax  (p.  76)  are  described 
elsewhere. 


92 


THE  SKIN 


Sycosis. — Sycosis  due  to  the  ordinary  staphylococcic  infection  appears 
on  the  hairy  part  of  the  face  in  the  form  of  papular,  papulopustular,  and 
nodular  lesions,  which  by  coalescence  produce  disfiguring  patches.  The 
distinction  from  tinea  sycosis  (barbers'  itch)  is  made  by  microscopic 
examination. 


Fig.   37 


Sycosis  vulgaris.     (Hartzell.) 


Impetigo. — Impetigo,  at  times  an  epidemic  and  apparently  contagious 
pus  infection,  appears  on  the  face  of  young  people  in  the  form  of  a 
vesicular  eruption  followed  very  shortly  by  rupture  of  the  vesicles  and 
the  formation  of  thin,  flat,  brown  crusts.  The  lesions  are  disseminated 
rather  than  grouped.  There  are  few  subjective  symptoms,  and  the 
affection  is  self-limited. 


THE  SKIN  93 

Pityriasis  Rosea.— Pityriasis  rosea  is  of  importance  to  the  practitioner 
because  it  bears  a  close  resemblance  to  lesions  of  secondary  syphilis. 
The  lesions  are  maculopapular,  rounded  or  annular  in  shape,  and  exhibit 
a  tendency  to  fine  scaling.  The  distinction  from  syphilis  is  based  on  the 
history,  on  the  results  of  treatment,  and  carefully  conducted  examination 
of  the  serum  obtained  by  attrition  and  cupping  of  a  lesion  for  the  spiro- 
chete. 

Lichen. — Lichen  is  a  chronic  affection  exhibiting  a  predilection  for  the 
flexor  surfaces  of  the  forearms  and  appearing  in  the  form  of  small,  flat, 
clearly  defined  angular  papules,  exhibiting  a  polished  red  surface.  These 
papules  coalesce,  forming  angular  patches.  There  is  usually  slight 
desquamation  and  much  itching. 

Fig.  38 


Lichen  planus.     Several  years'  duration.      (Hartzell.) 

Purpura. — Hemorrhage  of  the  skin  of  non-traumatic  origin  is  usually 
an  expression  of  pronounced  toxemia.  Its  first  appearance  suggests  an 
erythema,  but  the  color  cannot  be  made  to  fade  by  pressure.  Shortly 
the  characteristic  discoloration  of  effused  blood  becomes  manifest. 
Small  spots  are  termed  petechise;  larger  ones  are  termed  ecchymoses. 
Exceptionally  the  blood  effusion  may  be  so  pronounced  as  to  form  bullae. 
Lesions  are  usually  most  pronounced  in  the  lower  extremities. 

When  the  purpuric  eruption  occurs  in  the  course  of  fever,  or  is  associated 
with  arthritic  pains  and  swelling,  the  term  rheumatic  purpura  is  applied 
to  it.  It  is  not  infrequently  associated  with  urticarial  lesions,  gastro- 
intestinal crises,  or  bleeding  from  the  kidneys. 

Of  the  hypertrophies,  lentigo,  or  freckles,  chloasma,  or  patches  of  dis- 
coloration termed  liver  spots,  keratosis,  or  horny  thickening,  molluscum 
contagiosum,  corns,  and  warts  will  be  mentioned  in  discussing  the 
regions  of  predilection. 

Keloid. — Keloid,  usually  of  traumatic  origin,  is  characterized  by  an 
irregular  white  or  pink  nodulation  with  claw-like  extensions  into  the 
surrounding  skin,  usually  painless,  sometimes  itching  intensely,  and 
often  distinctly  vascular.  The  seat  of  predilection  is  the  skin  over  the 
sternum. 


94 


THE  SKIN 


Of  the  slowly  ulcerating  and  destructive  skin  affections,  those  due  to 
tuberculosis  and  syphilis  are  of  major  moment. 

Lupus  Vulgaris. — The  primary  tuberculous  skin  affection  usually 
begins  in  early  youth  by  the  formation  of  red,  raised,  soft,  jelly-like 
nodules  which  by  confluence  and  peripheral  growth  form  destructive 


Fig.   39 


Fibroma  moUuscum.  Smaller  lesions  are  sessile  and  overlying  skin  unaltered.  Larger  lesions 
pedunculated  and  lobulated.  Skin  is  thinned  and  adherent.  Neoplasms  consistency  of  soft  wax. 
(Duhring's  service:  Carnett.) 


lesions.  The  common  seat  is  the  face.  The  progress  is  extremely  slow. 
There  is  cicatrization  of  one  part  while  the  ulcer  is  extending  both 
superficially  and  in  depth  in  another. 

The  diagnosis  is  based  upon  the  presence  of  the  reddish  jelly-like 
lupoma  and  the  results  of  microscopic  examination. 

Lupus  Ersrthematosis.— This  appears  as  a  persistent  erythema,  often 
associated  with  seborrhea  and  branny  desquamation.  Neither  nodules 
nor  crusts  develop  and  the  lesion  is  very  commonly  symmetrical,  forming 
patches  on  either  cheek,  with  a  ridge  across  the  nose  connecting  them. 
This  affection  develops  at  a  later  period  of  life  than  lupus. 


PLATE  Vr 


S^s 

^^-      '  j'':   ^^Sl^k^kk.  ultesl 

1 

l^^j^Bl^ 

i 

^MkP 

4 

H^^HH 

P 

^r 

■s^i^P^^B 

l^H^ 

W 

Iflk^^^'C^'^ ''  '^^^^^^ 

^IH^k. 

f 

^i^^^l 

1 

^^^BK^^^^^^f^    .^,'^ig^flH 

^   1 

IBP'            .  ^_^,.:i^ 

^ 

r^^ 

\:'m 

.  ,.~<'»<'«>^     A^^m 

h^ 

^^ 

V: 

^EIuJMil^^nk  i4.-!L%n^-:- 

-\    m^MUKi 

% 

.      ^-                       ■       .v.- 

•  .       ^                                     -  -W        -.:-:--■:,    ■  ^.    ■--:        -•-,.   ^^  '   '        II 

Senile  Keratosis  Epithelioma.     (Hartzell.) 


PLATE  VII 


Pemphigus.      (Hartzell.j 


THE  SKIN 


95 


Sarcoma. — Sarcoma   of   the   skin   may  Fig.  40 

be  solitary  or  multiple.  In  its  pigmented 
form  it  often  originates  in  an  irritated 
nevus.  Some  forms  of  the  multiple  in- 
filtrating sarcomata  exhibit  a  tendency 
toward  self-limitation.  In  case  of  a  single 
growth  the  diagnosis  should  be  made  by 
excision  and  examination. 

Sarcoma  of  the  skin  may  appear  shortly 
after  birth  in  the  form  of  flat,  hard,  or  soft 
nodules,  exhibiting  rapid  growth. 

In  later  life  the  affection  may  develop 
in  the  form  of  a  hard  tumor,  which  can- 
not be  distinguished  from  fibroma  and 
which  may  remain  dormant  for  years. 

Exceptionally  the  tumor  is  formed  with 
such  rapidity  and  with  such  hyperemic 
symptoms  as  to  suggest  a  subacute 
abscess. 

Epithelioma. — Epithelioma  begins  as  a 
persisting  inflamed  patch  of  keratosis 
pigmentation  or  papillary  outgrowth, 
often  as  a  slight  trauma  which  refuses 
to  heal. 

The  rodent  ulcer  type  is  usually  placed 
on  the  face  above  the  level  of  the  nostrils ; 
the  fungating  type  affects  particularly  the 
lower  lip  of  males. 

Syphilis  as  a  causative  factor  must  be 
excluded.  The  rapid  growth  and  prompt 
adenopathy  of  chancre,  the  multiplicity 
and  polymorphism  of  secondary  lesions 
are  characteristic.  Tertiary  lesions  are 
usually  grouped  rather  than  single,  nor 

are  their  regions  of  predilection  usually  those  of  epithelioma.     They 
begin  as  infiltrations  rather  than  ulcerations. 

The  diagnosis  should  be  made  by    wide  excision  of  persistent  small 
ulcerations  occurring  in  those  past  middle  age. 


Lupus  vulgaris 
Duration,  years.      (Hartzell.) 


CHAPTER    VII. 

THE  BLOODVESSELS. 

As  the  result  of  trauma  a  bloodvessel  may  be  contused  or  partially  or 
completely  ruptured.  The  contusion,  in  case  the  inner  coats  have  been 
ruptured  or  distinctly  injured,  is  followed  by  thrombosis,  characterized 
by  loss  of  distal  pulse  if  arterial,  peripheral  congestion  and  edema  if 
venous,  and  local  tenderness  and  swelling.  If  the  thrombus  becomes 
acutely  infected,  abscess  will  develop,  and  may  be  followed  by  secondary 
hemorrhage  or  septic  embolism.  Partial  rupture  may  be  followed  by 
aneurysm. 

Wound  or  rupture  involving  all  the  coats  of  a  bloodvessel  is  followed 
immediately  by  blood  extravasation,  characterized  by  the  rapid  forma- 
tion of  a  fluctuating  tumor  which  may  pulsate  if  a  large  artery  be  in- 
volved. If  the  bleeding  be  into  the  pleura  or  peritoneum,  the  symptoms 
are  those  of  progressive  hemorrhage  with  the  evidence  of  free  fluid  in  the 
thoracic  or  the  abdominal  cavity.  Bleeding  into  the  brain  is  characterized 
by  pressure  symptoms. 

Arteritis. — The  effects  of  inflammation  of  the  arterial  walls  are 
lessened  elasticity  and  power  of  vasomotor  response,  diminution  in 
caliber,  the  formation  of  thrombi,  and  such  weakening  as  to  favor 
the  development  of  aneurysm.  Trauma  and  the  infections,  particularly 
the  staphylococcic,  streptococcic,  syphilitic,  typhoid,  and  rheumatic,  are 
the  usual  causes. 

The  local  symptoms  are  expressed  in  the  form  of  hardened  arteries, 
diminished  nutrition,  hence  lessened  vitality  and  impaired  or  altered 
function,  the  symptoms  of  thrombosis  and  embolism,  and  aneurysm. 

Phlebitis. — Phlebitis,  due  to  a  trauma  or  infection,  often  of  unknown 
origin,  is  expressed  in  the  form  of  venous  thrombosis,  usually  non-sup- 
purative  and  characterized  by  fever  and  leukocytosis  and  the  develop- 
ment of  a  painful,  tender,  cord-like  swelling  along  the  course  of  the  vein, 
with  dusky  and  edematous  swelling  of  the  overlying  skin  in  the  case  of  a 
superficial  vein,  or  pronounced  edema  of  the  parts  from  which  the  vein 
carries  the  blood  in  the  case  of  a  deep  one. 

The  left  femoral  vein  is  the  favorite  seat  of  thrombosis.  Typhoid 
fever  (third  week),  abdominal  operations  (convalescent  period),  pneu- 
monia (postfebrile  stage),  and  childbirth  are  predisposing  causes. 
Superficial  varicosities  and  lymphedema  are  sequelae. 

Thrombosis  and  Embolism.— Thrombosis  inevitably  follows  wounds, 
nor  is  it  unusual  after  clean  operations  for  small  emboli  to  be  carried  to 
the  lungs.  These,  if  not  infected,  occasion  few  symptoms  aside  from 
slight  cough  and  moderate  and  transitory  pleuritic  pain,  usually  on  the 
right  side,  attended  by  the  detection  of  friction  sound  on  auscultation. 


THE  BLOODVESSELS  97 

An  embolus  so  placed  as  to  produce  an  infarct  of  some  size  causes 
more  pronounced  symptoms,  together  with  a  bloody  expectoration. 
Such  infarcts  are  common  after  operation  on  incarcerated  and  strangulated 
hernias. 

When  an  embolus  lodges  in  the  pulmonary  artery  or  one  of  its  major 
branches,  symptoms  develop  at  once,  characterized  by  sudden  and 
urgent  dyspnea,  tumultuous  heart  action,  pale  face,  and  usually  dilated 
pupils.  This  attack  may  terminate  fatally  in  a  few  minutes,  or  partial 
recovery  may  take  place,  followed  by  a  new  crisis.  The  diagnosis  is  based 
on  the  history  of  a  recent  severe  traumatism,  operative  or  otherwise  or 
on  the  presence  of  a  venous  thrombosis. 

The  symptoms  of  fat  embolus  are  similar,  but  often  less  violent  in 
onset.  There  is  shock,  violent  dyspnea,  cyanosis,  cough,  often  blood- 
stained sputum,  sometimes  cerebral  excitement  characterized  by  delirium, 
or  torpor  or  coma.  There  is  a  general  elevation  of  temperature,  a  rapid 
small  pulse,  irregularity  of  the  heart  action. 

If  the  patient  lives  long  enough  for  the  test  to  be  made,  fat  will  be  found 
in  the  urine.  Fat  embolism  commonly  follows  injury  to  bone,  particularly 
that  largely  involving  the  cancellous  structure. 

Thrombosis  of  the  internal  jugular  vein,  usually  secondary  to  middle 
ear  infection  and  sinus  thrombosis,  is  characterized  by  a  tender  indura- 
tion along  the  course  of  the  vessel  and  pain  increased  on  motion. 

Thrombosis  of  the  hemorrhoidal  veins  is  characterized  by  pain, 
swelling,  and  sphincterismus.  The  severe  pain  of  sudden  onset,  called 
an  attack  of  piles,  is  due  to  rupture  of  a  vein  and  blood  extravasation. 

Thrombosis  affecting  the  deeper  veins,  characterized  by  pain,  fever, 
and  leukocytosis,  can  scarcely  be  diagnosticated  unless  there  be  an 
accompanying  suggestive  superficial  thrombosis.  Such  complication 
occurring  in  the  abdomen  following  operation,  or  in  the  course  of  typhoid 
fever  or  pneumonia,  may  simulate  an  acute  peritonitis. 

Thrombosis  of  the  superior  mesenteric  vein  is  less  common  than  an 
embolic  blocking  of  the  same  artery  which  it  may  accompany,  is 
characterized  by  similar  symptoms. 

Septic  thrombosis  incident  to  acute  progressive  infection  is  character- 
ized by  the  symptoms  of  thrombosis  with  those  of  abscess  added  thereto. 
It  is  an  occasional  cause  of  deep  abscesses  in  the  lower  extremity.  It  is 
the  usual  cause  of  abscesses  developing  in  regions  remote  from  the  seat 
of  original  infection  and  having  no  direct  lymphatic  connection  therewith. 
Infection  thus  carried  finds  lodgement  first  in  the  lungs  or,  if  it  be  derived 
from  the  collecting  branches  of  the  portal  circulation,  in  the  liver. 

Chill,  fever,  and  sweat,  irregularly  recurring,  and  profound  systemic 
depression  are  the  constitutional  expressions  of  such  transferred  infections 
with  the  symptoms  of  pylephlebitis,  bronchopneumonia,  or,  if  the  throm- 
bus be  carried  beyond  the  lung  capillaries  and  lodged  elsewhere,  local 
abscesses. 

The  kidney  is  a  favorite  seat  of  lodgem'ent  for  thrombi,  resulting,  if 
these  be  acutely  infectious,  in  the  formation  of  multiple  abscesses  at  the 
seats  of  infarct  and  complete  destruction  of  the  organ. 
7 


98  THE  BLOODVESSELS 

The  acute  osteomyelitis  of  adolescents  may  be  similarly  conveyed  from 
a  surface  infection  in  itself  of  minor  moment. 

Embolism  of  the  mesenteric  artery,  secondary  to  endocarditis,  or 
occurring  in  the  course  of  infection,  or  without  obvious  predisposing 
cause,  and  at  times  associated  with  a  thrombus  of  the  mesenteric  vein 
usually  causes  blood  stasis  and  gangrene  in  the  area  of  distribution  (small 
intestines).  The  symptoms  are  sudden  and  are  those  of  acute  peritonitis 
(p.  478).  A  history  of  previous  embolic  attacks,  or  the  presence  of 
valvular  heart  lesions  or  a  thrombosis  elsewhere  would  be  suggestive. 

Thrombosis  or  embolism  of  the  peripheral  arteries  is  characterized 
by  the  rapid  or  sudden  failure  of  the  peripheral  circulation.  There  is 
severe  pain,  absence  of  pulse,  and  the  part  becomes  cold,  livid,  painless, 
and,  if  collateral  circulation  is  not  established,  gangrenous.  Endocarditis 
with  dislodgement  of  vegetations  is  the  common  cause  of  the  larger 
peripheral  emboli.  The  arterial  block  occurring  in  the  course  of 
infections  may  be  embolic  or  thrombotic. 

Aneurysm. — Aneurysm,  a  blood  sac  which  communicates  with  an  artery, 
is  due  to  a  preexisting  vascular  lesion.  Exceptionally  it  is  traumatic, 
usually  it  is  a  consequence  of  arteritis.  The  affection  is  usual  in  middle- 
aged  athletic  Anglo-Saxons  who  have  had  syphilis  and  are  alcoholic. 
The  aorta,  the  popliteal,  the  femoral,  the  iliac,  the  subclavian,  and  the 
axillary  artery  are  the  ones  commonly  involved.  Broca's  formula  reads 
to  the  effect  that  as  one  grows  older  supradiaphragmatic  aneurysms 
become  commoner  and  those  beneath  the  diaphragm  rarer. 

In  shape  the  aneurysm  may  be  fusiform,  saccular,  or  distinctly  loculated, 
and  may  be  single  or  multiple.  In  its  progression  the  aneurysm  erodes 
both  soft  and  hard  tissues  lying  in  the  path  of  its  enlargement,  including 
the  bones  and  joints;  cartilage  exhibits  a  greater  resistance. 

The  characteristic  symptoms  of  aneurysm  are  the  presence  of  a  tumor 
in  the  region  of  an  artery  and  fixed  to  it,  which  exhibits  an  expansile 
pulsation,  thrill,  and  systolic  bruit,  which  are  abolished  by  proximal 
pressure.  In  the  vessel  distal  to  the  dilatation  a  retardation  and  soften- 
ing of  the  pulse  is  noted,  with  weakening  of  impulse  and  absence  of 
dicrotic  wave.  Pressure  symptoms  characterized  by  pain,  venous  con- 
gestion, and  at  times  paralysis  are  marked.  There  is  usually  a  steady, 
often  intermittent,  rapid  growth. 

In  spite  of  the  complete  symptomatology  of  aneurysm,  the  clinical 
distinction  between  this  condition  and  other  affections  is  not  always 
made. 

When  the  sac  becomes  greatly  thickened  by  deposit  of  laminated  clots 
the  characteristic  aneurysmal  symptoms  may  be  slight  or  wanting. 
When  the  tissues  around  the  aneurysmal  sac  become  inflamed,  either 
from  rupture  with  slow  leak  or  from  infection,  the  resemblance  to  abscess 
is  close. 

The  distinction  between  aortic  aneurysm  and  mediastinal  tumor  of 
other  form  is  often  made  correctly  only  at  postmortem.  Nor  are  the 
a;-rays  satisfactory  in  these  difficult  cases. 

On  general  principles  the  possibility  of  aneurysm  should  be  carefully 


THE  BLOODVESSELS  99 

considered  whenever  a  tumor  is  placed  near  or  upon  a  large  blood- 
vessel. The  history  of  the  case,  particularly  a  careful  examination, 
and  finally  aspiration,  will  usually  establish  the  diagnosis. 

Arteriovenous  aneurysm,  a  persistent  abnormal  communication  be- 
tween artery  and  vein,  usually  traumatic  in  origin,  is  an  affection  char- 
acterized by  a  soft,  compressible,  pulsating  swelling  exhibiting  thrill 
and  bruit  and  made  up  in  large  part  of  varicose  veins.  Pressure  symp- 
toms are  usually  not  so  well  marked  as  those  characteristic  of  arterial 
aneurysm,  though  cramps,  neuralgia,  and  anesthesia  are  common  in 
arteriovenous  aneurysm  of  the  extremities.  There  is  often  an  increase 
of  growth  in  the  affected  part,  sometimes  a  condition  resembling  elephan- 
tiasis; at  times  trophic  changes  and  ulceration.  The  condition  may  be 
entirely  lacking  in  subjective  symptoms. 

Angioma. — A  swelling  made  up  of  arterial  varicosities  is  called  cirsoid 
aneurysm;  when  the  veins  also  are  involved  it  is  called  aneurysm  by  anas- 
tomosis. These  tumors  (rare),  exceptionally  traumatic,  form  irregular, 
pulsating  swellings  beneath  the  skin,  through  which  the  tortuous  ves- 
sels are  readily  seen.  There  is  distinct  thrill  and  bruit.  The  scalp  is 
a  favorite  seat. 

Nevus,  or  birthmark,  is  the  common  form  of  angioma,  appearing  red 
or  blue  in  accordance  with  the  preponderance  of  arteriole  or  venule 
dilatation.  It  is  congenital  and  often  associated  with  lipomatous  deposits. 
It  may  be  markedly  pigmented  and  may  present  extraordinary  variation 
in  surface  configuration  and  color.  Telangiectasis  is  a  term  applied  to  a 
dilatation  of  the  skin  capillaries  acquired  usually  in  adult  life.  The 
lesions  are  usually  multiple,  and  may  be  widely  diffused  over  the  body,  but 
are  commonest  on  the  face.  Single  tortuous  vessels  may  appear;  usually 
they  are  grouped.  They  develop  in  regions  exhibiting  the  lesions  of 
chronic  acne  or  the  infiltration  of  rapidly  growing  tumor. 

Cavernous  angioma,  exhibiting  the  structure  of  erectile  tissue,  forms 
soft,  lobulated  swellings,  which  exhibit  marked  variation  in  size  incident 
to  changes  in  venous  pressure.  Such  a  tumor  may  be  mistaken  for  a 
cephalocele.  The  color  and  compressibility  of  the  cavernous  angiomata 
are  the  characteristic  features.  They  may  involve  the  greater  part  of  an 
extremity,  exhibiting  in  one  part  cystic  formation,  in  another  thick  fibro- 
lipomatosis.  The  difference  in  size  and  tension  incident  to  the  position 
of  the  leg  is  characteristic. 

Gangrene. — Gangrene  is  essentially  dependent  on  failure  of  the  blood 
supply  to  the  part.  This  may  be  due  to  traumatism  which  immediately 
and  completely  cuts  off  the  circulation;  to  inflammation  which  occludes 
the  lumen  of  the  vessels  by  thrombus,  aided  in  some  cases  by  the  direct 
pressure  of  the  inflammatory  exudate;  to  arteriosclerotic  occlusion  of 
the  arterial  lumen;  to  venous  thrombosis  producing  stasis  by  back 
pressure;  or  to  vasomotor  spasm  incident  to  disturbed  innervation.  In 
accordance  with  its  cause  gangrene  is  recognized  as : 

1.  Traumatic  gangrene,  due  to  crushing  and  destructive  violence, 
prolonged  devitalizing  pressure  or  constriction,  the  action  of  heat,  cold, 
or  chemicals.    It  may  be  dry  or  moist,  in  accordance  with  the  amount 


100  THE  BLOODVESSELS 

of  tissue  involved  and  the  completeness  with  which  saprophytic  and 
pyogenic  bacteria  are  excluded. 

Acute  spreading  gangrene,  particularly  incident  to  lacerated  contused 
wounds,  may  be  due  to  the  intensive  action  of  the  ordinary  pyogenic 
organisms  associated  with  the  putrefactive  and  gas-forming  germs,  or  to 
special  infection  by  the  bacillus  of  malignant  or  edema,  the  Bacillus 
aerogenes  capsulatus.  It  is  characterized  by  rapid  extension  of  cellulitis 
beyond  the  area  obviously  involved,  with  the  formation  of  gas  in  the 
tissues  and  the  constitutional  symptoms  of  profound  sepsis.  The  nature 
of  the  infecting  organism  is  determined  by  bacteriological  examination. 

2.  Embolic  gangrene.  If  peripheral  and  involving  large  vessels  the 
block  is  often  at  the  bifurcation  of  the  artery.  The  popliteal,  femoral, 
and  brachial  are  seats  of  predilection.  The  gangrene  may  appear  in 
the  dry  form,  affecting  the  fingers  or  toes,  and  may  be  followed  by  the 
moist  form  incident  to  secondary  infection,  involving  the  foot  and  leg. 

Thrombotic  gangrene,  if  incident  to  trauma,  would  be  suggested  by 
the  history  and  evidences  of  injury.  If  infective,  the  distinction  from 
embolic  gangrene  would  be  difficult. 

3.  Senile  gangrene,  predisposed  to  by  arteriosclerosis,  occasionally 
observed  in  the  young,  usually  precipitated  by  an  attendant  trauma  or 
slight  infection  of  the  part  involved,  or  thrombosis  at  the  seat  of  greatest 
arterial  lesion,  usually  attacks  the  feet  in  the  form  of  mummification. 

4.  Diabetic  gangrene  is  of  the  acute  infective  type,  and  is  favored  by 
tissues  of  poor  resisting  power  and  an  associated  arteritis  and  neuritis. 
It  is  characterized  by  the  rapid  sloughing  and  extension  of  a  trifling 
infection,  often  by  little  or  no  pain.  Except  when  associated  with  pro- 
nounced arteriosclerosis  and  directly  dependent  on  this  it  appears  in  the 
moist  form. 

5.  Angioneurotic  gangrene  exhibits  a  predilection  for  young  women, 
affecting  particularly  the  fingers  and  toes,  but  occurring  at  times  in 
symmetrical  patches  on  the  surface  of  the  body.  It  is  characterized 
by  a  preliminary  causeless,  extremely  painful  pallor,  numbness  and  cold- 
ness, followed  by  slow  necrosis. 

The  symptoms  of  gangrene  are  those  of  local  death,  i.  e.,  loss  of  pulse, 
heat,  sensation  and  motion;  livid,  finally  black,  discoloration,  with  mummi- 
fication or  putrefaction,  always  associated  with  vital  depression,  expressed 
in  the  form  of  acute  or  chronic  sepsis.  Whether  the  gangrene  be  of  slow 
or  sudden  onset  the  initial  symptoms  are  severe  pain,  lividity,  loss  of  heat, 
loss  of  pulse,  loss  of  sensation.     The  diagnosis  is  usually  obvious. 

Following  severe  contusion  there  may  be  discoloration  and  vesica- 
tion which  resemble  gangrene.  Preservation  of  pulse,  of  heat,  of  sen- 
sation, and  a  vitalized  skin  surface  beneath  the  vesications  establish  the 
nature  of  the  condition. 


CHAPTER    VIII. 

THE  LYMPH  VESSELS  AND  GLANDS. 

Rupture  of  the  Thoracic  Duct. — If  this  occur  without  peritoneal  involve- 
ment, it  results  in  an  extravasation  of  chyle  which  burrows  downward, 
becomes  sooner  or  later  infected,  and  opens  as  a  huge  postperitoneal 
abscess  in  the  groin,  closely  simulating  in  position  and  symptomatology 
psoas  abscess.  Associated  with  this  condition  there  will  necessarily  be  a 
rapid  emaciation.  Diagnosis  in  these  cases  has  usually  been  made  by 
the  continued  flow  of  chyle  after  evacuation  of  what  was  supposed  to  be 
a  psoas  abscess. 

The  usual  seat  of  wounding  of  the  thoracic  duct  is  at  the  root  of  the 
neck  during  extensive  operations,  such  as  removal  of  tumors  from  this 
region.  The  injury  has  been  recognized  at  the  time  of  operation  by  a 
continuous  flow  of  chyle  after  the  bleeding  has  ceased.  Usually  it  is  not 
suspected  until  an  abundant  flow  of  chyle  fills  a  closely  sutured  undrained 
wound  or  flows  from  the  drainage  openings. 

Progressive  wasting  rarely  follows,  the  circulation  of  the  chyle  being 
provided  for  by  collateral  channels. 

Lymphangitis. — Lymphangitis  incident  to  infection  may  be  acute  or 
chronic.  In  its  manifest  form  it  is  usually  secondary  to  a  virulent 
infection;  it  exceptionally  develops  after  contusion  or  strain.  It  is 
usually  associated  with  enlargement  of  at  least  the  group  of  lymphatic 
glands  into  which  the  involved  vessels  empty. 

A  general  reticular  lymphangitis  involving  the  small  divisions  of  the 
peripheral  lymphatics  is  not  an  unusual  sequel  of  infected  wounds. 
Because  of  its  resemblance  to  the  eruption  of  scarlet  fever  it  has  been 
named  surgical  scarlatina.  This  eruption  is  local  with  an  infecting  focus 
for  its  centre,  or,  if  otherwise  placed,  it  appears  in  patches  and  not  as  a 
diffuse  eruption,  nor  are  the  associated  lymphatic  glands  generally 
enlarged. 

In  its  ordinary  acute  form,  lymphangitis  is  characterized  by  rosy 
red,  slightly  edematous  streaks  corresponding  with  the  position  of  the 
lymphatic  vessels,  accompanied  shortly  by  enlargement  of  the  asso- 
ciated glands.  This  acute  form  of  infection  may  become  suppurative,  in 
which  case  nodular  swellings,  which  shortly  soften  and  discharge  pus, 
are  formed  along  the  course  of  the  vessels.  Such  suppuration  is  not  un- 
usual in  an  acute  lymphangitis  accompanying  chancroid  and  the  wounds 
contracted  in  postmortem  examinations.  The  resultant  abscesses  are 
characterized  by  an  abundant  thin,  purulent  discharge,  which  excep- 
tionally may  be  persistent  and  which  may  be  increased  by  dependent 
position  or  by  milking  the  parts. 


102  THE  LYMPH  VESSELS  AND  GLANDS 

In  place  of  circumscribed  abscess  there  is  more  likely  to  be  developed 
general  purulent  infiltration  of  the  surrounding  cellular  tissues.  Suppura- 
tion of  the  deeper  lymphatic  vessels  is  characterized  by  the  symptoms 
of  acute  cellulitis. 

The  distinction  between  lymphangitis  and  phlebitis  may  be  diflScult. 
Velpeau  stated  that  "phlebitis  can  be  palpated,  but  not  seen;  lymph- 
angitis can  be  seen,  but  not  felt" — a  dictum  which,  though  not  accurate 
in  its  expression  of  fact,  is  suggestive  as  to  the  differentiation. 

Chronic  lymphangitis  may  be  an  expression  of  either  local  or  systemic 
infection.  In  its  syphilitic  form  it  is  characterized  by  painless  indura- 
tion of  the  vessel  or  vessels  leading  from  a  chancre  to  the  associated 
group  of  lymphatic  glands.  Its  usual  position  is  on  the  dorsum  of  the 
penis,  where  it  can  be  picked  up  from  the  skin  and  rolled  between  the 
thumb  and  finger  as  a  hard  cord.  Palpable  fine  cords  corresponding 
to  the  direction  of  the  lymphatics  are  found  in  both  the  secondary  and 
the  tertiary  manifestations  of  syphilis. 

Tuberculous  lymphangitis  has  been  observed  most  frequently  as  a 
sequel  to  the  anatomical  ulcer  observed  on  the  hands  of  dissectors.  It  has 
developed  even  when  the  focus  of  skin  inoculation  could  not  be  demon- 
strated. The  affection  is  characterized  by  induration  extending  along 
the  course  of  the  lymphatic  vessels,  slow  (months)  in  development, 
persistent,  and  exhibiting  a  series  of  nodules  which  gradually  soften  and 
break  down,  forming  multiple  ulcers,  superficial  or  deep  in  accordance 
with  the  position  of  the  lymphatic  vessel  involved.  There  is  usually 
enlargement  and  softening  of  the  associated  lymphatic  glands.  Since 
other  chronic  infections  may  produce  these  lesions,  diagnosis  must  be 
based  on  the  finding  of  the  tubercle  bacillus  or  on  the  results  of  animal 
inoculation  and  the  tuberculin  test. 

Malignant  lymphangitis,  characterized  by  painless,  often  nodular 
enlargements,  is  always  associated  with  involvement  of  the  lymphatic 
glands.  It  is  usually  obscured  by  the  major  malady.  It  can  often  be 
detected  during  operation. 

Lymphangiectasis. — Lymphangiectasis,  or  dilatation  of  the  lymphatic 
vessels,  may  be  congenital  or  acquired. 

The  congenital  form  is  usually  manifested  in  infancy;  it  may  not 
form  an  obvious  swelling  until  later  in  life. 

Macrocheilia  and  macroglossia  and  lymphangioma  of  the  neck  and 
axilla  are  the  usual  expressions  of  congenital  cystic  dilatation  of  the 
lymphatic  vessels.  These  conditions  are  commonly  associated  with 
hemangioma. 

Acquired  lymphangiectasis  due  to  obstruction,  either  extrinsic  or  in 
the  vessel  itself,  and  in  the  latter  case  usually  incident  to  postinflamma- 
tory contraction,  is  commonest  in  the  groin  and  genital  regions,  form- 
ing here  at  times  a  diffuse,  soft,  slowly  growing  tumor,  which  never 
reaches  great  size,  which  is  lobulated,  is  distinctly  varicose,  and  is  to  an 
extent  movable  upon  the  deeper  parts  and  partly  reducible.  The  con- 
volutions of  the  dilated  vessels  can  often  be  seen  on  inspection  and  pal- 
pation, suggesting  the  sensation  which  is  conveyed  by  a  bundle  of  worms. 


THE  LYMPH  VESSELS  AND  GLANDS  103 

The  latter  distinguishes  this  condition  from  Hpoma,  while  translucency 
is  highly  characteristic  when  the  vessels  are  so  superficially  placed  that 
this  sign  can  be  elicited.  Associated  dilatation  of  the  vein  lower  down 
is  usually  characteristic  of  venous  varicosity  in  this  position. 

Obstruction  of  the  large  lymphatic  ducts,  if  the  collateral  circulation 
be  insufficient,  will  cause  not  only  lymphangiectasis,  but  also  lymph- 
edema; or  this  condition  may  develop  in  the  absence  of  obvious  dilatation 
of  the  lymphatic  vessels. 

Lymphedema. — Lymphedema  is  characterized  by  a  brawny  infiltration 
which  in  its  ultimate  development  produces  the  condition  known  as 
elephantiasis.  The  overlying  skin  is  thickened,  often  papillomatous, 
and  subject  to  dermatitis.  The  subcutaneous  tissues  are  those  mainly 
involved.     Ultimately  the  muscles  atrophy. 

This  condition  may  develop  in  any  part  of  the  body,  but  is  commonly 
encountered  in  the  leg  and  the  scrotum.  The  obstruction  causing  it  may 
be  due  to  repeated  inflammations,  producing  ultimate  narrowing  and 
obliteration  of  the  vessels,  to  infiltration  of  the  receiving  glands  (carci- 
noma and  tuberculosis),  or  their  removal,  or  to  lodgement  of  the 
filaria. 

The  diagnosis  of  the  latter  condition  depends  upon  the  associated 
hematuria  and  chyluria  and  the  finding  of  the  parasite  in  the  blood. 

In  its  slighter  development  lymphedema  is  often  associated  with  chronic 
leg  ulcer.  The  difficulty  in  healing  leg  ulcers  which  are  unassociated 
with  other  visceral  disease  or  obvious  venous  dilatation  is  probably 
incident  to  retarded  lymph  circulation,  due  to  a  chronic  lymphangitis, 
this  condition  not  being  sufficiently  developed  to  cause  obvious  lymph- 
edema. 

Lymphadenitis. — The  lymph  nodes  may  be  either  acutely  or  chronically 
inflamed. 

Acute  inflammation  is  usually  due  to  the  ordinary  pus  microbes  and 
is  characterized  by  the  formation  of  one  or  more  rounded  tender  swellings, 
over  which  the  skin  is  movable,  developing  in  the  glandular  group 
which  drains  an  infected  focus,  and  usually  associated  with  mild 
symptoms  of  septic  absorption.  If  the  affection  be  virulent  and  de- 
structive, the  nodule  or  nodules  are  quickly  obscured  by  periglandular 
edema  and  abscess  formation.  Inflammation  in  the  superficial  glands 
offers  no  diagnostic  difficulties. 

When  the  deeper  glands  are  involved  in  acute  suppurative  inflamma- 
tion, the  local  and  constitutional  symptoms  are  simply  those  of  deep 
phlegmon  the  glandular  origin  of  which  can  be  determined  only  by  the 
position  of  maximum  tenderness  and  swelling,  the  pain  radiations,  the 
interference  with  function,  and  the  finding  of  a  surface  infection,  which 
drains  by  the  lymphatic  vessels  to  the  region  involved.  Such  abscesses 
may  burrow  wide  of  their  original  seat.  Deep  local  tenderness  and  infil- 
tration and  superficial  edema  are  the  localizing  symptoms  which  guide 
the  diagnostic  and  curative  incision. 

Chronic  lymphadenitis,  an  occasional  sequel  of  acute  inflammation, 
usually  the  result  of  a  continued  and  frequently  repeated  mild  infection. 


104  THE  LYMPH  VESSELS  AND  GLANDS 

not  infrequently  tuberculous^  sometimes  syphilitic,  is  characterized  by  the 
enlargement  and  induration  of  a  single  gland  or  of  an  entire  group, 
unattended  by  pain  or  local  inflammatory  symptoms,  subject  to  recurring 
■subacute  attacks  with  rapid  variations  in  size,  terminating  either  in 
resolution  or  suppuration. 

Chronic  Non-tuberculous  Inflammatory  Hyperplasia.^ — This  is  commonly 
encountered  in  the  cervical  and  inguinal  regions,  less  frequently  in  the 
axilla.  In  the  cervical  region  it  is  usually  secondary  to  infections  of  the 
nose,  mouth,  throat,  or  ear.  In  children,  particularly  when  it  involves 
the  posterior  group  of  glands,  it  is  often  due  to  head  lice. 

The  affection,  if  the  cause  is  not  removed,  is  slowly  progressive  and 
results  in  softening  of  individual  glands  and  the  discharge  of  an  appar- 
ently sterile  pus  without  inflammatory  symptoms  more  marked  than 
those  needful  for  skin  perforation.  This  softening  takes  place  before 
the  glands  have  reached  the  size  of  a  pigeon's  egg,  and  usually  involves 
but  a  single  gland. 

These  cases  of  non-tuberculous  chronic  hyperplasia  are  rarely  seen  by 
the  surgeon,  since  the  enlargement  is  moderate  and  not  progressive  and 
the  tendency  is  toward  cure.  Most  of  the  cases  referred  to  him  are 
progressive  and  tuberculous. 

The  lymphatic  enlargement  of  beginning  Hodgkin's  disease  is  rapidly 
progressive,  the  tumor  shortly  reaching  a  size  beyond  that  encountered 
in  inflammatory  cases  while  still  preserving  its  normal  consistency. 

Chronic  adenitis  in  the  inguinal  region,  usually  secondary  to  urethral 
inflammation,  occasionally  maintained  by  a  fissure  or  other  anal  lesion, 
or  by  repeated  slight  trauma  of  the  feet,  or  following  excessive  coitus 
without  genital  lesion  or  assignable  cause,  is  distinguished  from  syphilitic 
bubo  by  the  absence  of  the  primary  sore  of  the  latter  disease  and  its 
different  evolutions;  from  tuberculous  adenitis  by  discovery  of  a  non- 
tuberculous  source  of  infection  or  by  the  failure  of  the  glands  to  undergo 
the  typical  tuberculous  evolution. 

Syphilitic  Adenitis. — Syphilitic  adenitis  is  a  customary  early  manifes- 
tation of  syphilitic  infection,  involving,  first,  the  glands  anatomically 
connected  with  the  seat  of  primary  lesion,  later  to  some  extent  all  the  lym- 
phatic glands  of  the  body.  The  syphilitic  buboes,  symptomatic  of  chan- 
cre, are  characterized  by  their  multiplicity  and  painlessness,  the  individ- 
ual glands  rarely  attaining  a  size  greater  than  the  last  joint  of  the  thiunb 
and  remaining  freely  movable  and  non-adherent  to  each  other  beneath 
the  skin.  The  glands  in  the  upper  postcervical  regions  and  those  placed 
in  front  of  the  internal  condyle  of  the  humerus  are  the  ones  whose  en- 
largement is  considered  particularly  characteristic  of  the  developing 
secondary  lesions.  Suppurative  adenitis  is  occasionally  observed  as 
the  result  of  mixed  infection. 

A  general  glandular  involvement  with  moderate  fever  and  the  muscle 
pains  of  toxemia  occurs  as  the  result  of  infections  other  than  syphilis. 
This  is  seen  in  la  grippe  epidemics.  The  distinction  from  syphilis  is 
based  on  the  absence  of  a  primary  lesion. 

Tertiary  syphilis  is  exceptionally  characterized  by  multiple,  indurated, 


THE  LYMPH  VESSELS  AND  GLANDS  105 

painless  glandular  swellings,  particularly  in  the  neck,  axilla,  the  elbow, 
and  the  groin. 

Gumma  (extremely  rare)  occasionally  develops  in  the  glands  of  the 
groin  and  neck.  The  progress  is  slow  (months);  softening  and  ulcera- 
tion occur  before  the  glands  reach  the  size  of  a  hen's  egg. 

The  diagnosis  in  the  infiltration  period  cannot  be  made  from  malignant 
growth,  except  by  a  consideration  of  the  history  and  the  finding  of  more 
characteristic  lesions  or  their  scars. 

There  is  a  phagedenic  form  of  ulceration  secondary  to  syphilitic  lymph- 
adenitis observed  in  the  groin.  The  skin  lesion,  incident  to  perforation 
of  the  abscess,  slowly  (months)  extends,  inducing  widespread  destruction 
of  both  the  superficial  and  the  deep  tissues. 

Tuberculous  Adenitis. — ^Tuberculous  adenitis,  commonest  in  ill-nourished 
girls  of  the  second  decade  but  observed  at  any  age,  strongly  predisposed 
to  by  heredity  and  affecting  by  preference  chronically  inflamed  glands, 
has  for  its  seats  of  predilection  the  neck,  the  groin,  and  the  axilla.  In  the 
neck  the  submaxillary  and  the  deep  cervical  nodes  commonly  are  first 
involved.  Tuberculosis  of  the  axillary  and  inguinal  nodes  is  less  fre- 
quent. 

In  its  early  stages  tuberculous  adenitis  cannot  be  distinguished  from 
inflammatory  hyperplasia  of  other  origin.  There  is  a  painless  induration 
and  enlargement  of  one  or  all  of  the  gland  group  which  may  persist  for 
months  or  years  without  change  other  than  gradual  growth  and  pro- 
gressive involvement  of  glands  lying  nearer  the  trunk.  As  a  rule,  a  gland 
group,  sometimes  the  entire  chain,  exhibits  the  symptoms  of  a  chronic 
periadenitis,  i.  e.,  the  surrounding  tissues  become  infiltrated  and  form 
part  of  the  tumor  mass,  and  individual  glands  soften  and  discharge 
through  the  skin,  leaving  ragged,  undermined  openings,  from  which 
there  is  a  continuous  running  of  thin,  curdy  pus. 

The  diagnosis  is  suggested  by  the  age  incidence,  the  chronicity,  the 
absence  of  pain  or  marked  tenderness,  the  tendency  to  extend  toward  the 
trunk  glands,  and  the  persistence  after  the  cure  of  an  infecting  focus 
which  might  account  for  chronic  inflammatory  hyperplasia.  The  diag- 
nosis should  be  strengthened  by  tuberculin  injection,  and,  if  needful, 
should  be  confirmed  or  disproved  by  removal  of  the  gland  before  the 
period  of  suppuration. 

Exceptionally  tuberculous  adenitis  presents  almost  the  identical  feat- 
ures of  Hodgkin's  disease. 

Hodgkin's  Disease. — Hodgkin's  disease,  occurring  usually  in  men,  is 
characterized  by  the  slow  or  rapid  growth  of  lymphatic  glands,  at  first 
distinct  from  each  other,  finally  merging  to  form  huge  masses.  There  is 
usually  an  associated  intermittent  fever.  The  blood  shows  no  changes 
excepting  diminished  hemoglobin  and  eosinophilia. 

This  affection  usually  begins  as  a  soft,  painless  enlargement  of  one  or 
two  of  the  cervical  glands,  or  of  the  axillary  or  inguinal  group.  At  this 
stage  the  preservation  of  normal  elasticity  and  consistency,  the  absence 
of  an  exciting  cause,  and  particularly  rapid  growth,  without  exhibiting  any 
tendency  toward  periadenitis  might  suggest  a  diagnosis.     Similar  growths 


106  THE  LYMPH  VESSELS  AND  GLANDS 

in  other  regions  shortly  make  the  nature  of  the  affection  plain.  Removal 
for  microscopic  examination  shows  usually  the  structure  of  the  normal 
gland  or  one  exhibiting  a  slight  degree  of  inflammatory  hyperplasia. 

Lymphatic  Leukemia. — Lymphatic  leukemia  is  characterized  by  similar 
enlargements  associated  with  tumefaction  of  the  spleen,  the  liver  and 
thymus,  and  bone-marrow  changes.  The  diagnosis  is  based  on  blood 
examination,  which  shows  marked  leukocytosis,  the  lymphocytes  being 
relatively  and  absolutely  enormously  increased  in  number.  The  myelo- 
genous form  of  anemia  is  characterized  by  leukocytosis  with  many 
myelocytes. 

Lymphosarcoma. — ^Lymphosarcoma  as  a  primary  affection  usually  in- 
volves a  group  of  glands,  presenting  precisely  the  picture  characteristic 
of  Hodgkin's  disease  with  the  exception  of  the  blood  changes.  The  growth 
is  rapid,  and  quickly  invades  the  surrounding  tissues.  The  diagnosis 
should  be  made  by  the  prompt  removal  of  the  soft,  rapidly  growing, 
apparently  causeless  gland  or  group  of  glands. 


CHAPTEK    IX. 

THE  MUSCLES,  TENDONS,  AND  BURS.E. 
THE  MUSCLES. 

Traumatisms.^ — Contusion. — Contusion  of  the  muscle  is  characterized 
by  a  condition  of  partial  palsy,  deep  pain,  local  tenderness  to  palpation 
and  on  movement,  swelling,  and  late  (days)  ecchymosis. 

If  there  has  been  extensive  blood  effusion,  which  always  implies 
muscular  rupture,  there  will  be  formed  rapidly  a  fluctuating  tumor, 
which  later  becomes  indurated  and  may  ultimately  exhibit  bony  hard- 
ness. 

Unless  the  nerves  be  involved,  atrophy  and  contracture  are  not  likely 
to  occur. 

Rupture. — ^Rupture  of  muscles  is  caused  by  violent  contraction  or  the 
direct  application  of  force  when  they  are  in  a  condition  of  contraction. 
Predisposing  factors  are  muscular  degeneration  such  as  follows  pro- 
longed fevers  and  overuse.     It  is  common  in  athletes  out  of  training. 

In  the  order  of  frequency  the  rectus  abdominis,  the  adductors  of  the 
thigh,  the  pectoralis  major,  the  deltoid,  the  midportion  of  the  quadriceps 
extensor,  the  muscles  of  the  back,  the  muscles  of  the  calf,  and  the  flexor 
muscles  of  the  legs  and  arms  are  the  ones  involved. 

The  rupture  may  be  fibrillary,  partial,  or  complete. 

Fibrillary  rupture  is  characterized  by  sudden  severe  pain,  disability, 
and  usually  tenderness  on  deep  pressure.  It  is  the  usual  cause  of  affec- 
tions called  sprained  back,  sprained  neck,  sprained  shoulder.  The  pain 
on  motion  and  tenderness  may  last  for  weeks  in  the  absence  of  immobili- 
zation. 

Complete  ruptures  usually  located  at  or  near  the  musculotendinous 
juncture,  and  characterized  by  a  feeling  of  something  having  given  way, 
are  accompanied  by  sudden  pain,  usually  extremely  severe;  immediate 
disability,  not  only  of  the  affected  muscle,  but  of  the  whole  muscle  group; 
tenderness;  gap  in  continuity  at  the  seat  of  break,  with  a  hard  lobular 
swelling  at  either  end  of  the  breach,  the  proximal  one  most  pronounced 
and  increased  in  size  and  hardness  by  efforts  at  contracture;  often  the 
rapid  formation  of  a  large  blood  tumor;  and  late  ecchymosis. 

A  central  partial  rupture  exhibits  the  symptoms  of  the  complete  rup- 
ture, the  pain  being  even  more  severe.  In  place  of  a  gap  in  continuity, 
there  is  formed  a  rounded  or  oval  tumor  which  becomes  denser  and  more 
pronounced  and  moves  upward  during  contraction  and  can  be  partially 
reduced  when  the  muscle  is  relaxed.  This  at  first  may  be  obscured  by 
tenderness  and  blood  effusion. 


108  THE  MUSCLES,  TENDONS,  AND  BURSJE 

Partial  rupture  may  recover  in  a  few  weeks.  Sometimes  it  becomes 
the  seat  of  osteoma.  Very  exceptionally  atrophy  results,  due  to  rupture 
of  the  nerve.     One  or  both  fragments  may  undergo  this  change. 

Hernia. — Hernia  of  the  muscle  (extremely  rare)  is  a  gradual  develop- 
ment, due  to  a  yielding  of  the  fibrous  sheath.  There  is  formed  a  small 
oval  tumor  without  subjective  symptoms.  It  is  soft  and  prominent  when 
the  muscle  is  relaxed.  When  the  muscle  is  forcibly  contracted  it  becomes 
hard  with  the  rest  of  the  muscle,  not  more  so,  and  either  partially  or 
completely  reduced.     There  is  but  slight  interference  with  function. 

Most  cases  reported  have  been  those  of  muscular  rupture.  From 
rupture  it  may  be  distinguished  by  its  slow  and  painless  development  and 
its  different  behavior  on  forced  contraction;  from  tumor,  by  the  fact  that 
the  latter  does  not  change  in  density  or  volume  incident  to  contraction 
either  voluntary  or  forced. 

Myositis. — Myositis  may  be  traumatic,  toxic,  or  infectious;  acute  or 
chronic.     It  is  exceptionally  suppurative. 

Infection  may  be  due  to  extension  of  inflammation  from  the  surround- 
ing parts,  or  may  occur  as  a  local  expression  of  systemic  poisoning,  in  the 
course  of  acute  infections  or  after  them.  Myositis  is  characterized  by 
extreme  pain  greatly  aggravated  by  motion,  tenderness,  swelling,  indura- 
tion and  contracture  producing  a  fixed  position. 

Traumatic  Myositis. — -Traumatic  myositis,  representing  the  reaction 
from  contusion,  sprain,  or  overuse,  is  typically  instanced  by  the  affec- 
tion of  the  extensors  of  the  leg  called  by  football  men  "Charley  horse,"  to 
a  less  degree  by  the  stiffness  and  soreness  of  any  group  of  muscles  subject 
to  unaccustomed,  violent,  or  prolonged  use.  It  predisposes  to  muscular 
rupture. 

Toxic  and  Infectious  Myositis. — ^Toxic  and  infectious  myositis,  usually 
rheumatic,  is  common  in  the  muscles  of  the  shoulder,  back  (lumbago),  and 
neck  (sternomastoid,  trapezius,  extensors).  It  is  always  a  symptom  of 
systemic  poisoning,  often  of  focal  origin  (appendix,  tonsils,  teeth,  sinuses 
of  the  head). 

Exceptionally  there  is  multiple  involvement,  the  skin  overlying  the 
affected  muscle  being  reddened  and  edematous,  the  muscle  below  swollen, 
tender,  hard  (sometimes  soft),  and  painful  on  movement. 

Suppurative  Myositis. — Suppurative  myositis  may  be  expressed  in  the 
form  of  localized  abscess  or  diffuse  phlegmon. 

A  localized  abscess  reaches  the  surface  slowly.  The  seat  of  suppura- 
tion is  characterized  by  an  almost  bony  hardness,  followed  by  softening, 
taking  place  in  days  or  weeks. 

Early  diagnosis  is  based  on  the  deep  seat  of  the  inflammation,  its 
acute  onset,  its  limitation  to  the  muscle  affected,  fixed  position  due  to 
contracture,  and  the  constitutional  symptoms  of  retained  pus. 

Diffuse  Phlegmonous  Myositis. — ^Diffuse  phlegmonous  myositis  occurs 
in  those  of  depressed  vitality  subject  to  prolonged  fatigue.  It  is  at  times 
a  sequel  to  trauma.  It  begins  with  characteristic  violent  septic  symp- 
toms and  severe  pains,  often  supposed  to  be  rheumatoid.  Nicaise  calls 
attention  to  the  frequency  of  head  symptoms,  particularly  pain  and  active 


THE  MUSCLES  109 

delirium  and  violent  agitation.  Constitutional  symptoms  may  entirely 
overshadow  the  local  lesion.  Tenderness  and  pain  in  the  muscle,  with 
contracture,  are  accompanied  by  an  edematous  thickening  not  so  clearly 
outlined  as  in  the  case  of  non-suppurative  myositis.  The  course  is 
extremely  acute,  much  like  that  of  osteomyelitis. 

Chronic  Myositis. — Chronic  myositis  may  follow  an  acute  attack.  In 
the  absence  of  other  demonstrable  cause  it  is  called  rheumatic.  It  is 
characterized  by  induration  and  slow  contracture. 

Ossifying  Myositis. — Ossifying  myositis  may  occur  about  the  seat  of  an 
old  fracture,  may  be  an  extension  from  osteoarthritis,  or  may  be  due  to 
muscular  trauma,  particularly  that  which  is  moderate  in  severity  and 
frequently  repeated.  Partial  muscular  rupture  is  particularly  a  predis- 
posing factor. 

Its  commonest  manifestation,  so-called  "rider's  osteoma/'  is  placed 
near  the  pubic  insertion  of  the  adductors.  There  may  be  multiple 
foci  of  ossification  in  the  muscle.  These  tumors  have  also  been  observed 
in  the  deltoid  and  brachialis  anticus,  and  occasion  little  distress  aside 
from  mechanical  interference  with  function. 

Progressive  ossifying  myositis  is  usually  observed  in  the  male;  some- 
times the  newly  born;  as  a  rule,  before  the  fifteenth  year.  There  is  a 
preliminary  swelling.  The  dorsal  muscles  of  the  spinal  column,  particu- 
larly those  in  the  cervical  region,  are  first  involved.  The  affection  is 
irregularly  progressive,  characterized  by  disseminated  areas  of  swelling 
in  the  muscle,  by  tenderness  and  often  skin  edema,  and  fixed  position. 
The  swellings  become  hard  and  finally  bony. 

Diagnosis  is  based  on  the  generalization  of  the  affection. 

Tuberculosis  of  the  Muscles. — ^Tuberculosis  of  the  muscles  is  usually 
secondary  to  neighboring  bone  or  surface  affection.  In  its  primary 
form  (rare)  it  may  appear  as  a  nodule  (tuberculoma)  or  cold  abscess  or 
general  infiltration. 

Tuberculoma  cannot  be  distinguished  in  its  early  stages  from  gumma 
or  neoplasm.  If  gumma  can  be  excluded  with  reasonable  certainty  the 
diagnosis  should  be  made  by  excision. 

Cold  abscess  of  the  muscle,  exceptionally  due  to  softened  primary 
muscle  tuberculoma,  usually  to  an  extension  of  tuberculous  infiltration 
from  bones  or  joints,  is  characterized  by  tumor  and  fluctuation  preceded 
by  the  symptoms  of  chronic  myositis  (contracture).  Acute  inflammatory 
symptoms  are  absent  until  the  skin  is  about  to  break. 

General  infiltration  occurs  secondary  to  bone  and  joint  tuberculosis 
and  is  followed  by  softening  and  abscess  formation. 

Syphihs  of  Muscles. — Myosalgia,  or  acute  muscular  pain,  is  a  common 
affection  of  early  syphilis;  indeed,  it  is  one  of  diagnostic  value,  especially 
as  it  occurs  about  the  shoulders  and  back  of  the  neck.  In  the  case  of  the 
sternomastoid  muscle  it  may  produce  torticollis. 

The  muscles  are  tender,  both  on  movement  and  palpation.  The 
affection  has  been  called  syphilitic  rheumatism. 

Syphilitic  myositis  attended  by  contracture,  particularly  common  in 
the  biceps,  also  observed  in  the  sternomastoid,  the  trapezius,  the  biceps 


no  THE  MUSCLES,   TENDONS,  AND  BURSJE 

femoris,  and  other  muscles,  occurs  in  the  first  year  of  the  disease  as  an 
expression  of  the  secondary  period.  It  is  characterized,  first,  by  mus- 
cular stiffness,  swelling,  and  hardness,  followed,  in  the  case  of  the 
biceps,  by  fixed  flexion  of  the  forearm.  Even  in  the  absence  of  syphilitic 
history  or  other  signs  of  the  disease  such  a  contracture  not  incident  to 
trauma  or  nerve  lesion  can  be  regarded  as  characteristic. 

Tertiary  syphilitic  myositis  is  characterized  by  swelling  and  induration 
which  may  be  diffuse  or  circumscribed.  The  diffuse  form  exhibits  the 
symptoms  of  the  secondary  involvement,  except  that  the  onset  is  more 
insidious,  the  course  slower,  the  swelling  greater,  the  contraction  more 
marked.  Pain  and  tenderness  may  be  severe  or  absent.  The  muscular 
structure  entirely  degenerates  and  is  replaced  by  fibrous  tissue.  The 
sternomastoid,  the  rectal  sphincter,  the  biceps,  pectoralis  major,  the 
deltoid,  the  common  extensors  of  the  fingers,  the  trapezius,  and  the  calf 
muscles  are  those  of  predilection.  The  early  diagnosis  is  of  major 
importance,  since  treatment  is  futile  after  muscular  degeneration  has 
become  complete. 

Gumma  of  the  muscle  may  begin  with  subacute  inflammatory  phe- 
nomena or  entirely  in  the  absence  of  these,  forming  at  first  an  ill-defined, 
slow-growing  (weeks)  infiltration,  later  a  rounded  or  elongated  tumor 
in  the  muscle  substance,  usually  near  the  region  where  the  latter  merges 
into  the  tendon.  Such  tumors  occasionally  involve  at  the  same  time  the 
same  muscle  on  the  two  sides  of  the  body.  They  may  undergo  absorp- 
tion and  sclerosis.  They  usually  soften  and  break  down,  forming  typical 
gummatous  ulcers. 

Neoplasms. — Neoplasms  of  the  muscles  are  usually  benign. 

Angioma  and  lymphangioma,  usually  congenital,  are  suggested  by  their 
softness,  obscure  outlines,  and  alterations  in  sizes,  incident  to  dependent 
and  elevated  positions  of  the  parts  in  which  they  are  placed;  often  they 
are  associated  with  cutaneous  and  subcutaneous  tumors  of  a  similar 
nature. 

Lipoma,  encapsulated  and  of  slow  growth,  may  be  inferred  from  its 
lobulation  and  softness. 

Enchondroma  is  characterized  by  its  density. 

Sarcoma  begins  precisely  as  do  the  benign  tumors,  gumma  and  tuber- 
culous infiltration.  It  is  distinguished  from  the  latter  clinically  only  in 
its  late  development,  growing  to  a  much  larger  size.  The  diagnosis  by 
any  form  of  examination  is  absolutely  impossible  at  the  time  it  is  ser- 
viceable. It  should  be  made,  if  gumma  be  excluded,  by  the  prompt 
excision  of  any  apparently  causeless,  rapidly  (weeks)  growing  tumor 
placed  in  the  muscle. 

Echinococcus  Cyst. — Echinococcus  cyst,  commonest  in  women,  is  char- 
acterized by  the  slow  growth  (years)  of  a  hard  rounded  muscle  tumor 
which  rarely  reaches  large  size.  Occasionally  this  tumor  gives  the 
so-called  hydatid  fremitus. 

Diagnosis  is  impossible  without  exploration,  since  the  hydatid  cyst 
may  exactly  simulate  gumma,  tuberculoma,  hematoma,  indeed,  any  of  the 
muscle  tumors. 


THE  MUSCLES  111 

Muscular  Contracture. — This  term,  implying  persistent  shortening  as 
contrasted  with  contraction,  which  indicates  the  intermittent  physiological 
process,  may  be  reflex,  postural,  myositic,  of  central  nerve  origin. 

Reflex  contracture  is  an  early  and  nearly  constant  symptom  of  arthritis 
and  peritonitis,  involving  the  muscles  whose  action  is  most  protective. 

Myositis  in  any  of  its  forms,  if  persistent,  is  followed  by  contracture 
due  to  the  formation  of  fibrous  tissue. 

Postural  contractures  are  such  as  are  observed  after  long  splinting  or 
fixed  position;  or  as  occur  sequent  to  failure  to  provide  against  the  effects 
of  gravity  and  unopposed  force  after  peripheral  palsies. 

Ischemic  contracture  palsy  due  to  pressure  which  cuts  off  blood  supply 
is  particularly  noted  in  the  forearm  after  tight  bandaging;  in  all  the 
extremities  after  the  Esmarch  tube.  It  may  follow  wounds  or  ligature 
of  larger  vessels.  The  degeneration  affects  muscular  fibers,  the  nerves 
themselves  remaining  intact.  It  is  characterized  by  contracture,  loss 
of  power,  and  atrophy. 

The  severe  forms  are  incurable. 

Atrophy. — Atrophy  of  muscles  is  due  to  non-use,  long-continued  con- 
tracture, as  from  inflammation  and  fixation  of  joints,  persistent  extension 
and  peripheral  nerve  lesions.  Atrophy  of  joint  inflammation  is  in  part 
reflex.  It  is  particularly  marked  in  the  deltoid  and  in  the  extensors  of 
the  thigh. 

Paralysis. — Paralysis  of  muscles  is  due  to  injury  or  disease  of  central 
or  peripheral  nervous  system  or  to  muscular  degeneration. 

Postanesthetic  Paralysis. — Postanesthetic  paralysis  may  be  central, 
hysterical,  reflex,  or  peripheral.  It  is  usually  peripheral,  and  follows 
prolonged  Trendelenburg  position  with  the  arms  hanging  over  the  head. 
Thus  is  pinched  the  brachial  plexus  against  the  transverse  vertebral 
processes,  between  clavicle  and  first  rib;  or  possibly  against  the  head  of 
the  humerus. 

The  upper  cords  are  most  injured,  as  expressed  by  paralysis  of  the 
deltoid,  biceps,  brachialis  anticus,  and  long  and  short  supinators.  All 
of  the  muscles  of  the  arm  may  be  involved. 

The  arm  resting  against  the  edge  of  a  table  may  compress  the  musculo- 
spiral  nerve,  causing  wrist-drop,  or  the  peroneal  muscles  may  be  paralyzed 
by  pressure  on  the  external  popliteal. 

The  diagnosis  is  based  on  the  finding  of  a  paralysis  not  present  before 
operation  and  by  the  rapid  and  progressive  development  of  the  reactions 
of  degeneration  in  severe  cases. 

Crutch  palsy  is  usually  expressed  in  the  muscles  supplied  by  the 
musculospiral  nerve;  those  innervated  by  the  median  or  ulnar  may  be 
involved. 

Obstetric  or  birth  palsy  following  difficult  labor  usually  involves  the 
brachial  plexus.  It  may  affect  the  mother  by  pressure  of  the  head 
upon  the  sciatic  or  obturator  nerve,  causing  pain,  contracture,  and  palsy. 
In  the  child  it  is  commonly  manifested  by  facial  palsy  from  forceps 
pressure;  or  brachial  plexus  palsy  usually  of  the  superior  root  type,  i.  e., 
deltoid,  biceps,  brachialis  anticus,  infraspinatus,  and  supinator  longus. 


112  THE  MUSCLES,   TENDONS,  AND  BURSM 

Reflex  palsies,  characterized  by  exaggerated  reflex,  moderate,  but 
persistent  atrophy,  and  diminution  in  electrical  excitability,  but  not  the 
reactions  of  degeneration,  are  such  as  are  observed  following  joint  trauma. 


THE  TENDONS. 

Trauma  of  the  Tendons.— Wounds. — Wounds  of  the  tendons,  usually 
obvious  on  inspection,  are  characterized  by  complete  loss  of  that 
motion  on  which  their  integrity  is  dependent.  When  the  tendon  is 
completely  divided,  often,  but  not  always,  there  can  be  felt  a  loss  of  con- 
tinuity, and  the  divided  ends  can  be  palpated,  the  proximal  one  moving 
with  contraction  of  its  muscle  and  often  retracted  from  the  wound. 

Rupture. — Rupture  of  the  tendons  is  characterized  by  sudden  pain,  the 
loss  of  motion  which  was  dependent  upon  the  integrity  of  the  tendon, 
and  usually  an  appreciable  gap  in  continuity,  filled  in  by  blood  which  can 
be  pushed  aside,  thus  allowing  the  two  extremities  of  the  tendon  to  be  felt. 
The  distinction  from  muscular  rupture  is  made  by  the  position  of  the 
break;  from  tearing  away  of  the  tendinous  insertion  of  the  bone; 
sometimes,  but  rarely,  by  bony  crepitus  or  palpation  of  the  bony 
fragment. 

Luxation. — Luxation  of  tendons  in  the  absence  of  complicating 
fracture  is  rare.  It  usually  affects  the  tendon  of  the  peroneus  longus. 
What  has  often  been  called  luxation  of  the  long  head  of  the  biceps  is 
usually  a  subacromial  bursitis. 

Tendon  luxation  is  accompanied  by  pain,  the  sensation  of  something 
having  given  way,  by  impaired  function,  and  local  tenderness.  The  dis- 
placed tendon  can  be  felt  and  reduced. 

Inflammation  of  the  Tendon. — Peritendinous  Cellulitis. — Peritendin- 
ous cellulitis  may  be  traumatic  or  infective,  and  involves  the  cellular 
tissue  immediately  surrounding  tendons  not  provided  with  an  investing 
synovial  sheath.  It  is  common  after  overuse,  and  in  the  foot  often  follows 
the  wearing  of  ill-fitting  shoes,  forming  a  tender,  puffy,  edematous  swelling 
on  either  side  of  the  tendo  Achillis,  which  gradually  fades  into  the  sur- 
rounding healthy  tissues. 

The  diagnosis  of  this  condition  is  based  on  the  position  of  the  swelling. 
If  the  infiammation  becomes  suppurative,  tendon  sloughing  is  likely  to 
result. 

It  is  distinguished  from  inflammation  of  the  bursa  by  the  fact  that  the 
outlines  of  the  latter  are  rounded  and  distinct. 

Syphilis  of  the  tendons  may  appear  as  infiltrations  or  small  gummatous 
nodules. 

Fibroma  and  fibrosarcoma  are  rare  tumors  of  tendons. 

A  fibrous  nodulation,  probably  traumatic,  of  the  flexor  of  a  finger 
causes  a  peculiar  locking  in  flexion  and  extension,  followed  by  a  sudden 
giving  way,  called  trigger  finger. 

Tenosynovitis. — ^The  infiammations  of  the  synovial  sheaths  of  tendons 
correspond  in  etiology,  and  to  some  extent  in  symptoms,  with  inflamma- 
tions of  other  synovial  sacs. 


THE  TENDONS  113 

The  inflammation  may  be  traumatic,  toxic  or  infectious,  acute  or 
chronic,  serous,  plastic  or  suppurative. 

Acute  tenosijnovitis  is  usually  due  to  overuse^ or^j^rain.  In  its  mildest 
form  it  represents  simply  a  hyperemia  and  a  slight  hypersecretion,  and  is 
termed  crepitant  tenosynovitis  from  the  fine  crackling  sensation  given 
when  the  tendon  slips  in  its  synovial  sheath  as  the  result  of  muscular 
contraction. 

Tenderness,  pain  on  motion,  and  crepitation,  elicited  by  grasping  the 
part  and  directing  the  patient  to  make  movements  which  require  contrac- 
tion of  the  muscle  of  the  involved  tendon,  are  the  characteristic  symptoms. 
The  swelling  is  slight.  There  may  be  a  rosy  edema  of  the  overlying  skin. 
The  tendons  commonly  involved  are  those  of  the  forearm,  wrist,  hand, 
and  ankle. 

If  the  trauma  be  severe,  there  is  distinct  effusion  not  only  within  the 
tendon  sheath,  but  in  the  surrounding  tissue,  forming  a  cylindrical 
swelling  in  the  course  of  the  tendon,  which  is  tender  to  pressure  and  on 
motion.     This  effusion  may  undergo  organization  fixing  the  tendon. 

Plastic  and  serous  tenosynovitis  are  occasionally  expressions  of  con- 
stitutional toxemia  or  infections  such  as  rheumatism,  la  grippe,  typhoid, 
pneumonia,  and  the  exanthemata.  They  are  usually  due  to  gonorrhea. 
The  effusion  is  fibrinous  rather  than  serous,  and  moderate  in  quantity. 
Exceptionally  it  is  abundant  and  undergoes  organization,  limiting  motion. 
This  is  particularly  likely  to  be  the  case  when  the  inflammation  of  the 
tendon  is  associated  with  a  gonorrheal  arthritis. 

Suppurative  synovitis  is  usually  due  to  direct  infection  through  a 
wound  or  to  extension  from  surrounding  soft  parts.  It  is  common  in 
the  tendons  of  the  finger  and  hand  secondary  to  panaris  or  palmar 
abscess,  and  is  characterized  by  a  tender,  edematous  swelling  extending 
along  the  tendinous  sheaths,  with  the  local  and  systemic  symptoms  of 
acute  extending  suppuration. 

Suppurative  tenosynovitis  is  often  followed  by  extensive  sloughing  of 
tendon,  or,  if  this  is  avoided,  by  firm  adhesion  of  the  tendon  to  its  sheath 
or  to  the  surrounding  soft  parts. 

Chronic  tenosynovitis  may  be  traumatic,  toxic  or  infectious.  It  is 
usually  tuberculous. 

Chronic  tenosynovitis  due  to  repeated  slight  traiuna,  or  to  overuse, 
appears  as  a  serous  effusion,  forming  a  soft,  fluctuating,  painless  tumor 
in  the  course  of  the  tendon  sheath.     This  is  rare. 

Tuberculous  tenosynovitis  appears  in  the  serous  or  fungous  form. 

In  the  serous  form  the  synovial  sheath  is  greatly  thickened,  distended 
by  a  thin  fluid,  and  contains  few  or  many  white  bodies  varying  greatly 
in  size,  looking  like  grains  of  half-boiled  rice.  The  enclosed  tendon  may 
be  quite  intact  or  may  be  fibrillated  and  torn  across. 

This  may  be  the  sole  demonstrable  manifestation  of  tuberculosis.  It 
often  follows  slight  trauma,  and  is  usually  found  in  the  common  sheath 
of  the  flexors  of  the  fingers.  Occasionally  it  involves  the  sheath  of  the 
extensors  of  the  hand  or  of  the  foot. 

It  is  characterized  by  slow  growth,  with  periods  of  acceleration  incident 
8 


114  THE  MUSCLES,   TENDONS,   AND  BURSM 

to  trauma,  and  in  the  hand  by  the  formation  of  a  characteristic  tmnor, 
non-sensitive,  fluctuating,  which  projects  in  the  palm  and  the  wrist  and 
is  divided  into  two  portions  by  the  annular  ligament.  There  is  usually 
a  crepitation  which  is  distinct,  and  has  been  compared  to  the  rubbing  of 
a  chain.  When  the  solid  bodies  are  few  or  absent  this  friction  sound 
cannot  be  elicited. 

The  muscles  of  the  tendons  involved  are  contractured  and  ultimately 
atrophy.  The  fingers  are  moderately  flexed  and  cannot  be  extended. 
When  the  sheath  of  the  extensor  tendons  of  the  hand  is  involved  a  globular 
swelling  forms  on  the  back  of  the  wrist. 

The  affection  is  slowly  progressive  (years).  Untreated  it  ultimately 
ulcerates  and  becomes  converted  into  the  fungous  form. 

Fungous  synovitis  is  usually  secondary  to  tuberculous  involvement  of 
bones  or  joints.  In  its  primitive  form  it  may  develop  as  an  expression 
of  general  tuberculosis  or  as  an  isolated  lesion.  The  synovial  lining  and 
often  the  tendons  themselves  are  invaded  by  a  mass  of  lowly  vitalized 
gelatinous  granulation  tissue. 

It  occurs,  as  a  rule,  in  the  young,  and  is  most  frequent  in  women.  The 
predisposing  factors  are  slight  trauma  or  repeated  irritation,  as  from 
excessive  use  of  certain  tendons.  It  occurs  particularly  in  the  sheaths 
of  the  common  flexors  of  the  fingers  or  those  of  the  thumb.  It  is  also 
observed  about  the  ankle. 

The  fungosity  begins  in  the  cul-de-sac  at  either  end  of  the  tendinous 
investment,  and  finally  involves  the  whole  sheath. 

The  onset  is  gradual,  being  attended  by  slight  soft  swelling  and  limita- 
tion of  motion.  The  further  progress  is  evidenced  by  a  slow  (months, 
years)  increase  in  swelling,  occupying  the  position  of  the  tendon  sheath. 
In  the  palm  the  swelling  is  bilobed  by  the  annular  ligament.  In  the  early 
stages  the  swelling  can  be  slightly  displaced  laterally  and  also  moves 
with  the  tendon,  showing  close  connection  between  the  two.  The  tendons 
at  first  become  fixed,  limiting  motion ;  later  they  soften  and  break.  This 
does  not  alter  the  fixed  position  of  the  parts,  since  the  distal  stump  of  the 
tendon  remains  adherent  to  its  sheaths.  Ultimately  (years)  softening 
occurs  with  tuberculous  ulceration.     Neighboring  joints  may  be  involved. 

This  affection  may  be  distinguished  from  syphilis  by  its  wider  diffusion, 
its  slower  course,  and  in  the  case  of  syphilitic  lesion  associated  specific 
lesions  and  the  therapeutic  test;  from  lipoma,  by  the  slower  course  of 
the  tumor,  absence  of  tendon  fixation  and  muscular  atrophy,  and  free 
mobility  of  the  part;  from  sarcoma,  by  the  rapid  growth  of  the  latter,  and 
by  operation;  from  tuberculous  arthritis,  the  late  stage  of  which  it  generally 
complicates,  by  the  location  of  the  swelling  and  the  x-ray.  After  sinus 
formation  the  depth  and  direction  of  these  and  the  presence  or  absence 
of  dead  bone  on  probing  will  suggest  the  diagnosis  of  the  seat  of  the 
affection. 

Syphilitic  tenosynovitis  may  take  the  serous  or  gummatous  form,  the 
former  during  the  secondary  period.  It  affects  by  predilection  the 
extensors  of  the  hand  and  foot.  It  is  insidious  in  onset,  exceptionally 
inflammatory,  may  be  symmetrical,  and  causes  but  trifling  disability. 


THE  BURS^  115 

Gummatous  tenosynovitis  (rare)  forms  an  induration  which  grows  to 
an  ill-defined,  hard,  rounded  tumor  in  the  course  of  weeks  or  months, 
usually  softening  before  reaching  the  size  of  the  end  of  the  thumb  and 
discharging  through  a  central  ulceration. 

Tumors  of  the  Tendon  Sheaths. — ^Tumors  of  the  synovial  sheath  are 
the  lipoma,  fibroma,  and  sarcoma. 

Lipoma. — Lipoma  has  been  observed  in  the  extensors  of  the  hand  and  in 
the  sheath  of  the  flexors  beneath  the  palm.  The  soft  tumor  simulates 
tuberculous  tenosynovitis;  it  does  not,  however,  fix  the  fingers  in  flexion 
with  muscular  atrophy.     The  diagnosis  must  be  made  by  incision. 

Fibroma. — Fibroma  (rare),  usually  observed  in  the  tendonsheaths  of  the 
fingers,  forms  small  hard  tumors  of  slow  growth.  In  their  first  develop- 
ment these  tumors  should  be  distinguished  from  sarcoma  by  excision  and 
by  microscopic  examination. 

Fibrosarcoma. — Fibrosarcoma  is  usually  observed  in  the  flexor  tendon 
sheaths  of  the  fingers  and  hand.  It  remains  small  and  quiescent  for 
years  and  then  begins  a  rapid  growth.  Until  this  period  of  growth  it 
exhibits  the  symptoms  of  fibroma,  nor  can  the  diagnosis  be  made  except 
by  excision  and  microscopic  examination. 


THE  BURS-ai. 

The  bursae  are  connective-tissue  sacs  with  an  endothelial  lining.  They 
are  antifriction  devices  which  secrete  a  synovial  fluid.  In  the  positions 
where  they  are  customarily  encountered  they  are  not  developed  until 
their  presence  is  required  by  muscular  activity,  hence  children  are  wanting 
in  many  of  them.  They  may  develop  in  regions  where  they  are  not 
customarily  found  as  the  result  of  pressure  and  friction,  and  are  then 
termed  accidental,  or  adventitious. 

Bursitis. — Bursitis  may  be  traumatic,  secondary  to  inflammation  of 
surrounding  parts,  or  a  local  expression  of  systemic  poisoning,  as  from 
the  acute  and  chronic  infectious  diseases  (gonorrhea,  rheumatism, 
exanthemata,  etc.). 

Acute  Bursitis. — Acute  bursitis  is  characterized  by  pain  increased  by 
motion,  tenderness,  often  crepitation  at  first,  later  fluctuation  in  the 
region  of  the  bursse.  If  the  exudate  is  fibrinous  or  serous,  there  will  be 
no  other  symptoms.  If  the  affection  is  suppurative  (secondary  to  infecting 
wound  or  peribursal  suppuration),  the  local  and  general  symptoms  of 
acute  suppurative  infection  will  be  present;  at  first  localized  to  the  bursa 
and  its  immediate  environment,  later  characterized  by  a  diffuse  phleg- 
monous infiltration  of  the  soft  parts,  or  even  of  the  joint,  causing  acute 
suppurative  arthritis.  The  distinct  localization,  clear  outlines,  and  rapid 
progression  of  the  inflammatory  tumor  are  in  the  early  stages  diagnostic. 
Even  when  suppuration  takes  place  the  general  inflammatory  edema 
will  be  found  to  focus  in  the  region  of  the  bursa.  It  is  only  when  the 
inflammation  has  been  aflowed  to  run  on  to  diffuse  phlegmon  that  the 
complications  obscure  the  original  lesion. 


116  THE  MUSCLES,  TENDONS,  AND  BURSM 

Chronic  Bursitis. — Chronic  bursitis  is  characterized  by  the  gradual 
formation  of  a  tumor,  usually  fluctuating,  exceptionally  translucent,  and, 
when  placed  beneath  a  tendon,  becoming  tense  or  flaccid  in  accordance 
with  the  position  of  the  joint.  It  is  usually  of  medium  size,  not  larger 
than  an  average  orange,  though  it  may  become  huge.  It  is  sharply  out- 
lined and  corresponds  in  position  with  that  of  a  normal  bursa  or  in 
history  and  mechanics  of  development  with  that  of  an  adventitious  one. 
Often  crepitation  and  at  times  the  rice-like  bodies  with  which  these  bursse 
are  frequently  filled  can  be  felt. 

The  fibrous  hemorrhagic  hygromata  so  exactly  simulate  tumor  that 
the  diagnosis  can  be  made  only  by  operation,  though  it  may  be  suspected 
from  the  anatomical  position  of  the  growth,  often  subject  to  transitory 
attacks  of  acute  inflammation. 

Acute  infection  of  a  chronically  inflamed  bursa,  often  following 
trauma,  usually  leaves  a  fistula  which  refuses  to  close.  The  nature  of 
this  fistulous  tract  is  determined  by  probing  and  exploratory  operation. 
The  x-rays  also  are  useful,  since  they  will  demonstrate  the  absence  of  a 
bone  lesion. 

The  sac  wall  may  be  greatly  thickened  or  even  cartilaginous  in  places 
and  closely  adherent  to  the  surrounding  parts,  or  even  surrounded 
by  a  dense  fatty  deposit.  The  inner  surface  may  be  clean,  may  exhibit 
vegetating  outgrowths,  or  in  gouty  patients  calcareous  concretions.  From 
organization  of  repeated  small  hemorrhages  of  the  sac  the  wall  may 
become  so  thick  as  to  suggest  solid  tumor,  the  fluid  contents  of  which  are 
entirely  obscured  by  the  rigid  sac.  Or  the  contents  may  be  solid  or  semi- 
solid, appearing  in  the  form  of  partially  organized  fibrin  or  granular 
debris. 

The  bursse  commonly  involved  in  chronic  inflammation  are  the  olec- 
ranal,  supra-acromial,  subacromial  or  subdeltoidean,  subiliac,  trochan- 
teric, prepatellar,  subpatellar,  pretibial,  semimembranosus,  popliteal,  and 
that  of  the  tendo  Achillis. 

Tuberculous  Bursitis. — Tuberculous  bursitis  usually  secondary  to  infec- 
tion of  the  neighboring  joints,  sometimes  primary,  is  especially  observed 
in  the  bursse  about  the  knee,  shoulder,  elbow,  and  hip-joint.  It  is  char- 
acterized by  tuberculous  infiltration  of  the  bursal  wall,  a  serous  effusion, 
ultimately  caseous  degeneration  and  the  formation  of  a  cold  abscess. 
In  its  comparatively  early  manifestation  the  affection  may  assume  either 
the  serous  or  the  fungating  form. 

Tuberculous  bursitis  is  characterized  by  tumor  in  the  position  occu- 
pied by  a  constant  or  an  adventitious  bursa.  This  tumor  offers  the 
characteristics  of  other  forms  of  bursal  effusion.  A  single  suggestive 
feature  is  its  causelessness.  The  diagnosis  may  be  made  by  excision 
and  microscopic  examination,  or  aspiration  of  the  bursal  contents  and 
injection  into  susceptible  animals.  The  ultimate  history  of  a  tubercu- 
lous hygroma  is  fistulization. 

Syphilitic  Bursitis. — Secondary  syphilis  may  cause  a  serous  effusion  in 
the  bursse,  with  inflammatory  symptoms  either  slight  or  wanting. 

Gummata  are  fairly  common,  particularly  in  the  prepatellar  and  the 


THE  BURS^  ]]7 

pretibial  bursse  and  that  of  the  olecranon.  Traumatism  is  a  predisposing 
factor.     The  affection  is  sometimes  symmetrical. 

Both  the  serous  effusion  and  gummata  are  characterized  by  the  absence 
of  subjective  symptoms  and  promptly  yield  to  specific  treatment.  The 
gummatous  affections  usually  soften  and  ulcerate,  forming  the  character- 
istic punched-out  ulcer.  The  distinction  from  tuberculosis  in  the  late 
ulcerating  cases  must  be  based  upon  the  history  and  the  associated 
lesions. 

Tumors  of  the  Bursa. — Sarcoma  is  the  commonest  bursal  tumor. 

Myxoma,  enchondroma,  and  fibrochondroma,  all  tumors  of  slow  growth, 
have  been  observed.  The  neighboring  joints  are  not  involved  and  the 
tumor  is  usually  movable  over  the  bone.  The  diagnosis  should  be 
suggested  by  the  existence  of  a  rapidly  growing  bursal  tumor  and  must 
be  confirmed  by  prompt  excision. 


CHAPTER    X. 

THE  BONES  AND  JOINTS. 
THE  BONES. 

Traumatism. — The  bones  may  be  bruised  or  broken. 

Contusion. — Contusion  is  characterized  by  pain,  usually  severe,  deeper 
placed  and  more  persistent  than  that  of  bruising  the  soft  parts,  by  ex- 
quisite tenderness  on  deep  pressure,  and,  if  the  bruised  bone  is  super- 
ficially placed,  by  palpable  swelling,  not  movable  over  the  underlying 
bone.  There  may  shortly  follow  this  injury  a  soft  subperiosteal  hema- 
toma. 

The  osteitis  resulting  from  the  contusion  usually  is  circumscribed  and 
undergoes  prompt  and  complete  resolution.  It  may  be  persistent  and 
be  followed  by  distortion  (coxa  vara)  or  by  bony  overgrowth.  Sup- 
purative or  tuberculous  osteitis  is  an  occasional  sequel. 

Fracture. — Commonest  in  males  except  at  the  extremes  of  life,  may 
result  from  either  direct  or  indirect  force  or  muscular  action. 

Direct  force  breaks  the  bone  at  the  seat  of  application;  indirect  force, 
in  the  case  of  the  long  bones,  usually  toward  their  extremities. 

The  fracture  may  be  simple,  the  line  or  lines  of  bone-break  not  com- 
municating with  a  skin  wound,  or  compound,  there  being  in  this  case 
such  communication.  The  break  may  be  incomplete  (green-stick 
fracture,  fissured  fracture)  or  complete. 

A  multiple  fracture  is  one  in  which  a  bone  is  broken  into  more  than  two 
fragments.  A  comminuted  fracture  is  multiple,  with  the  lines  of  cleavage 
intercommunicating. 

The  direction  of  the  break  is  usually  oblique ;  it  may  be  transverse 
(direct  violence)  or  spiral.  The  latter  frequently  in  the  bones  of  the  leg 
and  in  the  femur  and  humerus. 

The  deformity  of  the  fracture  may  be  angular,  transverse,  rotary,  or 
longitudinal.  Often  it  is  a  combination  of  these,  the  displacement  being 
produced  by  the  vulnerating  force,  muscular  contraction,  and  the  weight 
of  the  part. 

An  impacted  fracture  implies  the  driving  of  one  fragment  into  another 
so  firmly  that  preternatural  mobility  cannot  be  elicited. 

Fracture  from  muscular  contraction  is  usually  in  the  form  of  a  tearing 
off  of  a  shell  of  bone  at  the  point  of  tendon  insertion.  This  is  a  common 
complication  of  luxation.  The  ribs,  the  clavicle,  the  humerus,  any  of 
the  long  bones  may  be  broken  through  their  long  axis  by  muscular 
action  alone. 

Birth   fractures  are  comparatively  common   following  instrumental 


THE  BONES  119 

or  manual  delivery,  or  even  in  the  absence  of  these.  The  bones  of  the 
skull  are  those  which  suffer  most.  The  clavicle,  femur,  and  humerus 
are  also  frequently  involved. 

Spontaneous  fracture,  by  which  is  meant  the  break  of  a  bone  from 
trifling  force,  should  always  suggest  either  a  local  or  a  systemic  predis- 
posing condition. 

Among  the  predisposing  conditions  are  osteomyelitis,  suppurative, 
tuberculous,  or  syphilitic;  infiltrating  or  eroding  tumors;  rickets;  osteo- 
malacia; senility;  pregnancy;  locomotor  ataxia;  psychoses;  paralysis,  and 
disuse  atrophy.  The  diagnosis  is  often  not  made  until  visible  deformity 
calls  attention  to  the  lesion,  since  those  spontaneous  fractures  have  few 
subjective  symptoms  and  often  occur  in  patients  whose  major  malady 
inhibits  function.  There  is  at  times  an  enormous  outgrowth  of  callus 
attending  union  which  is  usually  slow  and  often  never  takes  place. 

Aside  from  the  causes  predisposing  to  fracture  already  given  there  is 
a  bone  fragility  of  unknown  origin  unassociated  with  other  lesions,  some- 
times congenital,  often  persisting  through  life  and  characterized  by 
many  fractures  which  heal  kindly.      This  is  called  fragilitas  ossium. 

The  diagnosis  of  fracture  is  based  on  the  presence  of  one  or  all  of  its 
cardinal  symptoms:  (l)  Abnormal  mobility;  (2)  deformity;  (3)  crepitus. 

The  abnormal  mobility  is  detected  by  direct  palpation  at  the  seat  of 
break  supplemented  in  the  case  of  the  long  bones  by  extension,  and, 
where  this  is  applicable,  attempts  at  angulation.  It  is  absent  in  green- 
stick  and  fissured  fractures,  and  in  those  which  are  impacted. 

Deformity,  often  obvious  on  inspection  and  palpation,  is  usually  cor- 
roborated by  mensuration  and  the  x-rays.  It  is  absent  in  fissured 
fractures.  It  may  be  present  only  when  produced  by  manipulation  in 
subperiosteal  and  epiphyseal  fractures  and  in  breaks  of  bone  naturally 
splinted  by  either  another  bone  or  muscle,  as  in  the  case  of  the  fibula,  ribs, 
or  scapula. 

Crepitus  is  detected  by  rubbing  the  broken  ends  of  the  bone  together. 
This  is  accomplished  by  direct  manipulation  or  by  pulling,  angling, 
and  rotatory  movements  of  the  distal  fragment,  the  proximal  one  being 
fixed.  Crepitus  can  be  distinctly  felt  as  a  grating,  and  can  be  heard  by 
the  naked  ear  or  by  means  of  a  stethoscope.  It  is  absent  in  incomplete 
and  impacted  fractures  and  in  those  the  broken  surfaces  of  which  cannot 
be  brought  into  apposition  either  because  of  wide  separation  or  inter- 
position of  soft  parts. 

In  addition  to  these  cardinal  fracture  symptoms  there  are  those  of  all 
severe  trauma,  i.  e.,  pain,  disability,  swelling,  and  discoloration,  the  latter 
coming  on  late  (days). 

Pain  and  tenderness  are  felt  at  the  seat  of  fracture,  and  both  are  per- 
sistent even  in  the  absence  of  deformity.  Disability  is  usually  pro- 
nounced. 

Swelling  and  late  discoloration  not  due  to  direct  trauma  are  extremely 
suggestive  symptoms. 

Sugar,  indican,  and  fat  are  commonly  found  in  the  urine  after  fracture 
and  are  of  some  slight  diagnostic  value. 


120  THE  BONES  AND  JOINTS 

The  fever  reaction,  rarely  over  100°,  for  one  to  three  days,  is  that 
common  to  trauma. 

The  examination  for  fracture  cannot  be  considered  complete  until  the 
presence  or  absence  of  lesions  of  important  nerves  and  bloodvessels  lying 
near  the  seat  of  injury  has  been  determined. 

Within  twenty-four  hours  there  very  commonly  develop  about  the 
seat  of  fracture,  particularly  when  the  tibia,  humerus,  or  both  bones  of 
the  forearm  are  broken,  large  vesicles  filled  with  blood-stained  serum. 
These  blisters,  often  attributed  to  irritating  dressing,  are  quite  indepen- 
dent of  the  latter. 

Fractures  which  lie  partly  or  wholly  within  the  joints  in  addition  to 
the  symptoms  common  to  all  fractures,  are  characterized  by  a  rapid 
distention  of  the  articular  cavity,  due  to  free  bleeding  and  later  serous 
effusion.  Because  of  the  rapid  swelling  and  marked  tenderness  attend- 
ing these  joint  fractures,  the  examination  is  rarely  satisfactorily  diag- 
nostic unless  it  be  made  by  the  x-rajs  or,  in  the  absence  of  these,  by  the 
aid  of  an  anesthetic. 

Delayed  union  may  be  due  to  local  or  systemic  cause.  It  is  character- 
ized by  preternatural  mobility  persisting  at  the  seat  of  fracture  after  the 
period  (four  weeks)  when  consolidation  should  have  taken  place.  It  is 
usually  associated  with  tenderness  on  motion,  marked  disability,  and  hard 
swelling  due  to  hyperabundant  callus.  Exceptionally  callus  formation 
is  totally  wanting.  The  local  conditions  usually  at  fault  are  imperfect 
apposition,  inadequate  mobilization,  the  interposition  of  soft  parts; 
exceptionally,  inflammatory  lesions  or  malignant  infiltration. 

Ununited  Fracture.— This  condition  represents  a  persistence  of  delayed 
union  beyond  the  period  when  there  is  a  reasonable  expectation  of  union 
without  surgical  intervention  (twelve  weeks).  Its  causes  and  symptoms 
are  those  of  delayed  union. 

Diagnosis  is  based  on  the  detection  of  preternatural  mobility;  this  is 
usually,  but  not  always,  associated  with  pain  greatly  aggravated  by 
attempts  at  function.  Unnatural  mobility  is  at  times  difficult  to  elicit. 
The  a--rays  may  be  needed  for  diagnosis. 

Vicious  union  due  to  improper  apposition  or  inadequate  retention  is 
usually  manifest  on  inspection.  At  times  it  is  dependent  on  callus  for- 
mation which  by  its  bulk  interferes  mechanically  with  movement,  exerts 
a  crippling  pressure  on  muscles,  tendons,  nerves,  and  bloodvessels,  or 
binds  the  bones  which  normally  move  upon  each  other,  as,  for  instance, 
the  radius  and  ulna,  thus  preventing  pronation  and  supination. 

Inflammation  of  Bones. — Inflammation  may  be  traumatic  or  infec- 
tive, acute  or  chronic. 

Acute  Traumatic  Osteoperiostitis. — ^This  is  the  expression  of  reaction 
against  a  bone  bruise,  characterized  by  localized  tenderness  to  deep 
pressure  and  the  formation  of  a  subperiosteal  swelling,  which  may 
undergo  organization  into  bone. 

Osteomyelitis  always  follows  a  more  extensive  injury,  such  as  fracture, 
and  is  the  process  essential  to  repair.  When  the  neck  of  the  femur  is 
involved,  the  softening  incident  to  a  persistent  inflammation  may  predis- 
pose to  marked  deformity. 


THE  BONES  121 

Acute  Infective  Inflammation  of  the  Bones. — This  may  appear  in  the 
form  of  an  osteoperiostitis  or  osteomyelitis.  The  usual  pus  organisms, 
particularly  the  staphylococcus,  are  the  causative  agents.  Other  organ- 
isms are  occasionally  at  fault. 

Acute  Suppurative  Osteoperiostitis. — Acute  suppurative  osteoperiostitis, 
in  its  frankly  suppurating  form,  is  either  traumatic  or  due  to  extension 
of  inflammation  from  neighboring  soft  parts.  The  local  and  general 
symptoms  are  those  of  pus  under  tension,  the  pain  being  severe. 

Acute  Syphilitic  Osteoperiostitis. — ^ Acute  syphilitic  osteoperiostitis  at 
times  precedes  the  skin  eruption;  usually  it  develops  at  about  the  same 
time.  It  is  characterized  by  extremely  painful,  hypersensitive,  slightly 
elastic  swellings,  involving  by  preference  the  bones  of  the  cranium,  the 
tibia,  the  ribs  and  the  sternum.  The  overlying  skin  may  be  reddened 
and  edematous.  The  diagnosis  is  based  on  associated  syphilitic  symp- 
toms. 

Typhoid  Osteoperiostitis. — ^Typhoid  osteoperiostitis  exceptionally  de- 
velops in  an  acute  form,  appearing  as  a  tender,  painful  bone  swelling, 
usually  on  the  sternum,  ribs,  or  tibia,  preceded  by  severe  bone  pain  and 
attended  by  moderate  fever.  This  form  of  typhoid  osteoperiostitis  is 
prone  to  develop  during  the  convalescing  period.  It  may  undergo 
resolution.  Usually  it  breaks  down,  exposing  an  area  of  superficial 
necrosis. 

When  it  attacks  the  vertebr£e,  persistent  crippling  pain  and  disability 
are  the  cardinal  symptoms. 

Gonorrheal  Osteoperiostitis. — Gonorrheal  osteoperiostitis  in  its  acute 
form  exhibits  a  predilection  for  the  calcaneum,  causing  pain  and  tender- 
ness on  the  plantar  surface  of  the  heel. 

Acute  Infective  Osteomyelitis. — Acute  infective  osteomyelitis  affects 
mainly  the  long  bones  of  growing  boys,  particularly  those  of  depressed 
vitality  who  have  been  subject  to  slight  trauma  or  severe  chilling, 
and  who  have  an  infecting  focus  such  as  a  boil  or  an  inflamed  tonsil. 
The  Staphylococcus  aureus  is  the  common  infecting  germ;  in  virulent 
cases  the  streptococcus  may  be  found.  The  pneumococcus,  the  colon 
and  the  typhoid  bacillus  are  also  at  times  causative  factors. 

Acute  osteomyelitis,  though  it  begins  at  or  near  the  epiphyseal  line, 
usually  extends  in  the  direction  of  the  diaphysis.  The  femur  and  tibia 
are  the  bones  of  election.  The  radius,  the  fibula,  the  pelvis,  the  ulna, 
the  inferior  maxillary  bone  follow  in  order.  The  affection  is  often  mul- 
tiple. Acute  osteomyelitis  usually  terminates  in  necrosis,  which  may  be 
localized  or  may  involve  the  entire  shaft  of  a  long  bone.  Exceptionally 
it  infects  the  neighboring  joint,  being  then  complicated  by  suppurative 
arthritis.  It  not  infrequently  becomes  quiescent  or  chronic,  with  a  life- 
lasting  tendency  to  recurrence.  Exceptionally  it  undergoes  complete 
resolution. 

Growing  pains  probably  represent  an  ephemeral  form  of  osteomyelitis, 
especially  when  they  are  characterized  by  slight  tenderness  near  one  or 
more  joints,  recurring  and  starting  pain  and  prompt  subsidence  under 
rest. 


122  THE  BONES  AND  JOINTS 

Destruction  or  separation  of  a  growing  epiphysis  may  result  in  de- 
formity or  developmental  failure. 

As  the  result  of  softening  and  during  the  period  of  convalescence 
spontaneous  fracture  is  at  times  observed,  particularly  in  the  tibia,  fibula, 
and  humerus. 

As  observed  in  infants  and  young  children,  acute  osteomyelitis  attrib- 
utable to  infection  carried  from  the  stump  of  the  umbilical  cord  or 
from  other  suppurating  skin  or  mucous  membrane  lesion,  may  develop 
as  an  acute  arthritis,  the  epiphyseal  focus  of  infection  promptly  breaking 
into  the  neighboring  joint. 

The  diagnosis  of  acute  osteomyelitis  is  based  on  the  sudden  or  rapid 
development  of  the  constitutional  symptoms  of  virulent  sepsis,  asso- 
ciated with  severe  local  pain,  great  tenderness,  best  elicited  by  prolonged 
deep  pressure,  or  bone  percussion,  disability  so  complete  that  in  infants 
paralysis  is  often  suspected  and  shortly  (two  days)  edema  of  the  over- 
lying soft  parts.  Skin  redness  and  fluctuation  become  obvious  in  the 
course  of  days  or  weeks  if  death  from  septicemia  does  not  occur  before 
this. 

The  systemic  infection  of  osteomyelitis  may  so  closely  resemble  that 
of  typhoid  that  the  conditions  may  be  confused  when  the  seat  of  bone 
infection  is  not  accessible  to  direct  examination,  as  in  the  case  of  acute 
inflammation  of  the  vertebrae,  of  the  mastoid  process  of  the  temporal 
bone,  or  of  the  upper  extremity  of  the  femur.  The  leukocytosis  of 
osteomyelitis  is  characteristic,  and,  if  searched  for,  localizing  symptoms 
generally  can  be  found. 

The  bone  pains  of  the  eruptive  fevers  and  of  meningitis  are  shortly  fol- 
lowed by  other  characteristic  symptoms;  moreover,  they  involve  many 
bones.  Rheumatism  involves  joints  primarily  and  is  attended  by  rapid 
swelling  and  tenderness,  elicited  by  direct  joint  pressure,  while  in  osteo- 
myelitis there  is  usually  a  point  of  maximum  tenderness  in  the  juxta- 
epiphyseal  line,  and  the  swelling  of  the  soft  parts  does  not  become 
obvious  for  two  or  three  days. 

Chronic  Inflammation  of  the  Bone. — Chronic  osteomyelitis  is  char- 
acterized clinically  by  thickening,  sometimes  lengthening,  of  the  bone. 
It  is  usually  associated  with  pain.  It  may  be  traumatic  or  infective.  In 
its  development  it  may  be  formative,  causing  pronounced  overgrowth  of 
bone,  or  destructive,  as  expressed  by  caries,  necrosis,  and  sinus  formation. 
These  processes  are  commonly  combined.  The  infective  form  is  usually 
tuberculous  or  syphilitic.  Occasionally  it  is  an  expression  of  either 
feeble  or  well-resisted  pyogenic  infection. 

Chronic  Traumatic  Osteomyelitis. — This  is  either  a  sequel  of  severe 
trauma  inadequately  treated  or  is  incident  to  repeated  slight  trauma. 
It  is  characterized  by  pain,  aggravated  by  use,  tenderness,  and  bone 
enlargement,  or  distortion  due  to  overgrowth  or  softening.  This  form 
of  osteomyelitis  is  instanced  by  the  bony  deformities  about  the  ankle  and 
wrists  following  unrecognized  fissured  fractures,  and  by  the  bending 
of  the  femoral  neck,  entitled  coxa  vara. 

The  diagnosis  of  chronic  traumatic  osteomyelitis  must  be  based  upon 


THE  BONES  123 

the  history  of  the  case,  the  relief  of  symptoms  incident  to  rest,  the  findings 
of  the  a;-rays,  and,  if  the  case  has  been  observed  late  (years),  the  absence 
of  all  tendency  toward  abscess  formation,  steady  or  rapid  growth,  or 
progressive  deformity.  In  its  earliest  stages  it  may  readily  be  confounded 
with  tuberculous  osteomyelitis. 

Chronic  Infective  Osteomyelitis.^ — Chronic  infective  osteomyelitis  in  its 
superficial  form,  the  so-called  osteoperiostitis,  is  usually  an  expression  of 
syphilis,  gonorrhea,  typhoid,  or  rheumatism. 

In  its  deep  form  osteomyelitis  is  usually  tuberculous,  sometimes 
syphilitic,  exceptionally  an  expression  of  the  irritating  effects  of  other 
infecting  organisms,  particularly  those  of  the  pus  group  and  the  typhoid 
bacillus. 

The  osteoperiostitis  of  syphilis,  an  expression  of  the  late  secondary 
or  early  tertiary  period  of  the  disease,  appears  in  the  form  of  hard 
bosses,  involving  by  preference  the  tibia,  ulna,  and  the  frontal  and 
parietal  bones,  usually  moderately  painful,  sometimes  excessively  so, 
slightly  tender  and  slowly  progressive  (weeks) .  These  bosses  may  soften 
and  discharge  through  a  sinus,  which  later  becomes  an  ulcer  of  con- 
siderable size,  exposing  carious  bone,  or  may  undergo  organization, 
leaving  prominent  bony  bosses  which  form  permanent  records  of  a  con- 
stitutional infection,  and  are  quite  unaffected  by  treatment.  The  diag- 
nosis is  based  on  the  history  of  syphilis,  associated  lesions  of  the  disease, 
and,  in  the  infiltrating  stage,  the  prompt  resolution  as  the  result  of  efficient 
treatment. 

Chronic  Rheumatic  Osteoperiostitis  (rare). — This  is  a  term  applied  to  a 
form  of  bone  infection  in  which  the  organism  cannot  be  found.  It  is 
characterized  by  local  pain  and  progressive  swelling  which  may  either 
soften  slowly  (weeks),  discharging  a  serous,  sterile  fluid,  or  may  undergo 
resolution,  leaving  thickened  bone. 

Gonorrheal  osteoperiostitis  exhibits  a  predilection  for  the  calcaneum. 
It  is  usually  formative  in  nature,  causing  a  bony  outgrowth,  which  makes 
walking  or  pressure  painful.  Similar  outgrowths  are  observed  in  the 
absence  of  gonococcal  infection  and  are  possibly  traumatic  or  rheumatic. 
The  diagnosis  is  made  by  the  a;-rays. 

Tuberculous  Osteomyehtis. — Tuberculous  osteomyelitis  is  the  common- 
est form  of  chronic  bone  inflammation.  It  is  characterized  by  its  insidious 
onset,  predilection  for  the  epiphyses  of  the  young,  slow  progression,  and 
ultimate  destructive  tendency. 

Slight  trauma  is  the  most  important  predisposing  factor. 

Pain  is  usually  the  first  symptom  of  tuberculous  osteitis,  varying  greatly 
in  intensity,  worse  at  night,  aggravated  by  use,  and  associated  with  some 
tenderness.  It  is  at  times  entirely  lacking,  involvement  of  the  neighbor- 
ing articulation  being  the  first  sign. 

Swelling  gradually  develops,  forming  in  the  case  of  the  long  bones 
of  the  hands  and  feet  the  spindle-shaped  tumor  called  spina  ventosa. 

On  the  sternum,  ribs,  and  radius  the  infection  may  remain  superficial, 
forming  painless  tumors  which  gradually  soften  and  discharge  a  cheesy 
pus  through  a  sinus  which  leads  to  carious  bone. 


124  THE  BONES  AND  JOINTS 

The  bones  in  their  order  of  involvement  are  (Nelaton)  vertebrae, 
tibia,  femur,  humerus,  phalanges,  metatarsals  and  metacarpals,  sternum, 
ribs,  iliac  bones,  tarsals  and  carpals,  petrous  portion  of  the  temporal 
bone. 

In  the  case  of  bones  deeply  placed  the  symptoms  are  usually  those  of 
arthritis  or  cold  abscess  which  may  open  near  the  seat  of  bone  disease 
or  burrow  wide  of  this,  as,  for  instance,  the  psoas  abscess  of  Pott's  dis- 
ease, forming  fluctuating  tumors  without  appreciable  symptoms  of  local 
inflammation.  Later  they  ulcerate  and  discharge  a  characteristic  cheesy 
pus,  often  with  small  fragments  of  bone.  Probing  or  the  x-ra,js  lead  to 
the  detection  of  dead  bone.  Sometimes  the  tuberculous  process  becomes 
encysted  and  quiescent. 

Since  in  its  early  stage  tuberculous  osteomyelitis  is  characterized  only 
by  moderate  pain,  associated  with  local  tenderness  if  the  part  be  acces- 
sible, or,  if  the  focus  of  infection  be  near  a  joint,  with  synovial  effusion, 
the  diagnosis  is  not  possible  unless  destruction  of  bone  substance  has 
been  sufficient  to  give  a  distinct  aj-ray  picture. 

The  causelessness  and  persistence  of  such  pain  and  tenderness  are, 
however,  suggestive. 

The  swelling,  which  shortly  becomes  palpable  in  the  case  of  bones 
superficially  placed,  such  as  the  ribs,  sternum,  tarsal  bones,  and  phalanges, 
lacks  the  characteristics  of  acute  infection,  and,  if  syphilis  can  be  ex- 
cluded, should  be  diagnosticated  by  incision  and  microscopic  examina- 
tion, as  a  distinction  from  malignant  growth  is  at  this  stage  not  possible. 

Since  the  joint  symptoms  of  tuberculous  osteomyelitis  may  be  the  first 
to  attract  attention  to  the  affection,  the  diagnosis  of  the  underlying  lesion 
is  based  upon  the  probability  of  its  existence,  as  nearly  every  tuberculous 
arthritis  is  secondary,  and  on  the  findings  of  the  x-rays. 

Syphilitic  Osteomyelitis. — Syphilitic  osteomyelitis,  usually  a  tertiary 
manifestation  of  the  disease,  may  be  either  circumscribed  or  diffuse. 
In  its  infiltrating  stage  it  is  a  common  cause  of  spontaneous  fracture. 
It  causes  pronounced  hyperplasia  of  the  bone,  and,  if  untreated,  usually 
terminates  in  necrosis  and  sinus  formation.  The  seats  of  election  are 
the  tibia,  humerus,  nasal  septum,  palate,  cranial  bones,  and  the  inner 
third  of  the  clavicle. 

When  it  attacks  the  bones  of  the  nose,  mouth,  and  face,  it  usually 
begins  as  a  painless  bone  swelling,  which  because  of  its  position  is  often 
unnoticed.  The  destruction  of  bone  is  extremely  rapid  (days  or  weeks), 
but  is  unattended  by  widespread  acute  inflammation  of  the  soft  parts  or 
pronounced  constitutional  symptoms.  Painless  perforations  of  the  palate 
and  the  nasal  septum  are  in  themselves  almost  diagnostic  of  syphilis. 
Gummata  of  the  cranium  at  times  cause  intolerable  anguish;  usually 
they  are  painless. 

Syphilitic  osteomyelitis  of  the  metacarpals  and  phalanges  is  char- 
acterized usually  by  the  almost  painless  development  of  a  fusiform  bone 
swelling  which  in  the  course  of  weeks  softens  and  tends  to  discharge. 
The  diagnosis  between  this  condition  and  tuberculous  osteomyelitis 
cannot  be  made  from  the  local  appearance  of  the  lesions.     The  syphilitic 


THE  BONES  125 

lesion  is  more  likely  to  be  symmetrical,  involving  the  two  hands.  Both 
are  observed  in  infants  and  children;  either  may  occur  in  the  adult. 
Tuberculous  involvement  is,  however,  somewhat  more  frequent  at  a 
later  age. 

Syphilitic  osteomyelitis  involving  the  long  bones  is  attended  by  the 
pain,  tenderness,  and,  if  the  inflammation  be  near  the  joint,  the  serous 
effusion,  fixation,  and  muscular  atrophy  which  are  regarded  as  character- 
istic of  tuberculous  osteomyelitis. 

If  the  syphilis  manifest  itself  in  the  form  of  a  circumscribed  gumma, 
the  symptoms  may  be  identical  with  those  of  a  beginning  sarcoma. 

The  diagnosis  must  be  made  by  careful  consideration  of  the  history, 
the  results  of  a  thorough  trial  of  specific  treatment,  and,  in  some  cases, 
the  findings  of  the  x-rays. 

The  bone  manifestations  of  hereditary  syphilis  are  characterized 
shortly  after  birth  by  a  thickening  of  the  epiphyseal  osteochondral 
plates  so  marked  that  in  accessible  joints  distinct  tumor  may  be  felt. 
In  two  or  three  months  the  process  of  softening  may  reach  such  a  stage 
as  to  cause  juxta-epiphyseal  fracture,  usually  characterized  by  a  pseudo- 
paralysis, since  there  may  be  no  displacement  because  of  the  thickened 
periosteum,  nor  bone  crepitus.  A  child  of  six  months  presents  precisely 
the  appearance  of  one  suffering  from  rickets. 

Periosteal  outgrowths,  sunken  nose,  high  vaulted  palate,  and  sabre- 
shape  nodular  tibias  represent  typical  results  of  the  hereditary  form  of  the 
disease. 

Chronic  osteomyelitis  which  is  neither  syphilitic  nor  tuberculous  is 
commonly  a  sequel  to  an  acute  attack,  and  is  due  to  the  ordinary  pus 
organisms,  exceptionally  to  other  forms  of  microbian  infection.  The  bone 
is  always  thickened,  sometimes  enormously  so,  about  the  area  of  suppura- 
tion or  necrosis,  the  pus  often  being  found  sterile  to  bacterial  investiga- 
tion. There  may  be  a  large  sequestrum  unattended  by  suppuration. 
The  affection  is  characterized  by  pain  located  in  the  bone,  aggravated  by 
use  and  subject  to  periods  of  exacerbations ;  swelling  of  bony  hardness, 
which  may  be  found  only  in  the  epiphyseal  region,  shading  off  gradually 
into  the  diaphysis,  or  which  may  involve  the  entire  shaft,  tenderness 
often  elicited  only  by  deep  and  prolonged  pressure  or  by  percussion,  and 
by  somewhat  characteristic  a;-ray  showings. 

The  favorite  seats  of  circumscribed  abscess  are  at  either  extremity  of 
the  tibia,  particularly  the  upper,  and  the  lower  extremity  of  the  femur. 
When  the  condition  is  associated  with  a  serous  effusion  into  the  nearest 
joint  the  distinction  from  tuberculous  osteomyelitis  may  be  quite  impos- 
sible without  exploratory  and  curative  operation. 

Malignant  growth  in  its  early  stage  affords  precisely  the  clinical  pic- 
ture of  a  localized  chronic  osteomyelitis,  excepting  that  the  onset  and 
progression  of  the  newgrowths  are  more  rapid.  When  tumor  has 
developed,  neoplasm  always  gives  a  more  distinct  outline  from  the  sur- 
rounding bone  than  is  afforded  by  the  overgrowth  of  tissue  incident  to  a 
chronic  osteomyelitis. 

The  diagnosis,  suggested  by  a  previous  acute  attack  of  osteomyelitis, 


126 


THE  BONES  AND  JOINTS 


should  be  made  by  the  a:-rays  and  by  early  incision,  providing  gumma 
can  be  excluded. 

Rickets. — This  is  an  affection  of  infancy,  but  sometimes  of  late  devel- 
opment, supposed  to  be  due  to  malnutrition,  common  in  those  of  syphilitic 

parentage.     Its   acute  form   (rare) 
Fig.  41  is  characterized  by   painful   swell- 

ing of  the  ends  of  the  long  bones, 
usually  diagnosticated  and  treated 
as  rheumatism. 

The  customary  mode  of  onset 
is  by  gradual  impairment  of  health, 
juxta- epiphyseal  bone  swellings, 
and  mechanical  deformities  incident 
to  softening. 

A  rickety  child  exhibits  a  bossed 
forehead,  open  fontanelles,  delayed 
dentition  of  deformed  and  rapidly 
rotting  teeth,  high  palatal  vault, 
alveolar  flaring  in  the  upper  jaw,  the 
reverse  of  this  in  the  lower,  beaded 
ribs  (rachitic rosary),  chicken  breast, 
pot-belly,  spinal  curvature,  usually 
anteroposterior,  and  enlarged  epi- 
physes. 

The  distinction  from  hereditary 
syphilis  by  the  symptoms  alone  is 
impossible. 

Osteomalacia. — Osteomalacia,  an 
affection  of  adults,  exceptionally 
observed  in  children  and  in  the 
aged,  sometimes  epidemic,  most 
frequently  affects  gravid  women 
who  have  borne  many  children  in 
quick  succession,  and  is  character- 
ized by  tenderness,  softness,  and 
flexibility  of  the  bones  and  rapid  loss  of  height,  associated  with  impaired 
general  health,  cutaneous  hyperesthesia,  and  exaggerated  reflexes. 
Spontaneous  fracture  is  common  and  exhibits  little  tendency  toward 
healing.  From  gravity  and  the  pull  of  muscles,  deformities  are  rapidly 
developed,  particularly  curvature  of  the  spine.  Exceptionally,  multiple 
cysts  are  found  in  the  bone,  forming  symmetrical  tumors. 

The  diagnosis  in  the  early  stage  may  be  suggested  by  distinct  and  wide- 
spread bone  tenderness  and  pain.  Later,  when  the  bones  become  flexible, 
deformities  are  produced,  and  spontaneous  fractures  occur,  at  least  the 
name  of  the  malady  is  readily  suggested. 

When  it  attacks  the  aged,  osteomalacia  is  particularly  characterized 
by  bone  pain  and  tenderness  involving  especially  the  ribs  and  spine, 
associated  with  muscular  contracture,  inducing  anteroposterior  curva- 


Rickets.      Large  head;  protuberant  abdomen; 
bowing  of  tibiae.      (Carnett.) 


THE  BONES  127 

ture.  There  is  almost  complete  helplessness.  This  is  particularly  the 
case  when  the  condition,  as  is  common,  is  associated  with  spontaneous 
fracture. 

Osteitis  Deformans. — Osteitis  deformans,  or  Paget's  disease,  an  affection 
of  the  elderly,  usually  associated  with  arteriosclerosis,  and  indicative  of 
a  predilection  toward  malignant  growth  of  the  bone,  is  characterized  by 
deformities  which  are  due  to  combined  processes  of  absorption  and 
overgrowth.  The  bones  of  the  leg  are  the  first  to  be  obviously  affected, 
though  an  early  symptom  attracting  attention  may  be  the  need  for 
getting  a  hat  of  larger  size.  As  a  rule,  pain  located  in  the  bone,  at  times 
of  exhausting  severity,  initiates  the  affection,  followed  in  the  case  of  the 
legs  by  weakness,  stiffness,  and  bowing  and  thickening  of  the  diaphyses 
of  the  long  bones,  is  usually  symmetrical.  The  progress  of  the  dis- 
ease is  slow  (years).  It  may  remain  in  the  part  first  affected  or  may 
become  generalized.  The  diagnosis  is  based  on  the  dissemination  of 
the  lesions  and  their  slow  progression. 

From  syphilitic  osteomyelitis  the  affection  is  distinguished  by  its  much 
slower  course,  its  wide  diffusion,  the  absence  of  a  tendency  to  necrosis  and 
sinus  formation,  and  failure  to  respond  to  specific  treatment,  though  the 
latter  will  be  equally  futile  even  in  cases  of  syphilis  when  the  formative 
changes  incident  to  irritation  have  reached  their  complete  development. 

Achondroplasia  is  a  congenital  affection  akin  to  rickets  in  its  bone 
manifestations. 

The  few  children  who  survive  are  symmetrically  headed,  long-bodied, 
pot-bellied  dwarfs,  with  short, extremities  and  big  epiphyses. 

Osteogenesis  Imperfecta. — Osteogenesis  imperfecta  is  a  congenital 
afi^ection  characterized  by  multiple  fracture  incident  to  imperfect  bone 
formation.  Children  who  survive  are  of  low  stature  and  are  short- 
legged.  The  diagnosis  is  based  on  the  occurrence  of  multiple  fractures 
from  inadequate  cause. 

Acromegaly. — Acromegaly  is  a  chronic  painless  affection  due  to 
disease  of  the  pituitary  body,  insidious  in  onset,  slow  in  progress,  and 
characterized  by  gigantic  growth  of  the  hands,  feet,  face,  and  head. 
The  soft  parts  participate  in  the  overgrowth  of  bone,  though  the 
nails  remain  of  normal  size.  The  gross  face,  projecting  eyebrows,  big 
tongue,  large  nose,  bulging  occipital  protuberance,  enlarged  mastoid 
processes,  thick  lips,  and  coarse  features  are  characteristic.  There  is 
an  associated  testicular  atrophy  in  men;  in  women,  enlarged  clitoris 
and  vagina  and  hypertrophied  larynx,  giving  them  a  bass  voice.  The 
thymus  gland  is  enlarged. 

Perhaps  the  most  diagnostic  feature  of  the  affection  is  the  slow  and 
apparently  causeless  increase  in  the  size  of  the  hands  and  feet. 

Tumors  of  the  Bone. — Osteoma.— Osteoma,  a  benign  tumor  of  slow 
growth  and  extreme  hardness,  is  usually  fixed  to  the  underlying  bone. 
Either  local  or  diffuse  hyperostosis  is  a  common  expression  of  chronic 
inflammation.  During  the  period  of  epiphyseal  growth  and  consolidation, 
usually  before  puberty,  exostoses,  often  spur-shape,  but  exhibiting  great 
diversity  of  conformation,  and  capped  with  cartilage,  develop,  origin- 


128  THE  BONES  AND  JOINTS 

ating  near  the  epiphyseal  line  and  growing  toward  the  diaphysis.  These 
cease  growing  when  the  epiphyses  have  reached  full  development.  Their 
seats  of  predilection  and  greatest  development  are  the  bones  of  the  fore- 
arms and  legs,  though  they  may  occur  toward  the  extremities  of  any  of 
the  long  bones.  They  are  characterized  by  causelessness,  multiplicity, 
slow  growth  ceasing  with  maturity  and  absence  of  symptoms  aside  from 
those  incident  to  their  bulk. 

The  affection  is  often  hereditary. 

The  diagnosis  of  all  forms  of  osteomata  is  based  on  the  slowness  of  growth, 
the  absence  of  symptoms  other  than  those  incident  to  mechanical  inter- 
ference and  pressure,  the  a;-rays  and  excision  and  microscopic  examina- 
tion. Exceptionally  after  injury  about  the  knee  there  is  a  comparatively 
rapid  development  of  a  tender^  painful  osteoma.  This  can  be  distin- 
guished from  beginning  sarcoma  only  by  excision  and  microscopic 
examination. 

Exostoses  of  the  sinuses  of  the  cranial  bones  conform  to  type  in  that 
they  develop  slowly,  usually  in  young  adults,  and  manifest  their  pres- 
ence only  by  pressure  symptoms,  usually  beginning  with  a  sinusitis,  later 
followed  by  tumor  developing  in  the  case  of  the  frontal  sinus  in  the 
direction  of  the  orbit.     The  x-rays  give  a  characteristic  picture. 

Chondroma. — Chondroma,  often  an  hereditary  affection,  has  for  its  seat 
of  predilection  the  bones  of  the  hands  and  feet.  The  tumor  may  be 
single  or  multiple,  and  frequently  gives  a  traumatic  history. 

Chondromata  are  characterized  by  the  slow  (years)  growth  of  a  painless, 
usually  lobulated,  hard,  elastic  tumor,  which,  if  subperiosteal,  may  be 
covered  by  a  thin  shell  of  bone.  Pressure  ulcers  may  occur  in  the  soft 
parts  when  the  tumor  has  attained  great  size. 

The  centrally  placed  enchondromata  may  give  rise  to  severe  pain  and 
spontaneous  fracture.  Moreover,  in  their  transitional  (usually  malignant) 
forms  these  tumors  may  become  soft  and  grow  rapidly. 

The  distinction  from  sarcoma  in  the  early  stage  of  the  growth  should 
be  made  by  excision.  Later,  the  slow  extension  of  the  chondroma, 
distinct  encapsulation,  and  sometimes  enormous  size  are  sufficiently 
characteristic  of  the  nature  of  the  tumor. 

In  its  pelvic  development  chondroma  commonly  springs  from  near 
the  sacroiliac  synchondrosis,  exceptionally  from  the  pubic  region. 
Growth  is  rapid  and  characterized  by  density,  fixation,  and  pressure 
symptoms,  particularly  in  the  direction  of  the  sciatic  and  obturator 
nerves.  The  distinction  from  malignant  growth  can  be  made  only  by 
excision. 

Lipoma. — Lipoma  of  the  bone  (rare)  may  be  congenital,  inflammatory, 
or  neoplastic.  The  congenital  lipoma  may  be  placed  at  or  near  the 
epiphyses,  particularly  that  of  the  upper  portion  of  the  femur.  It  may 
be  pedicled  or  sessile  and  not  infrequently  causes  bone  erosion.  This 
form  of  lipoma  may  grow  rapidly.  It  is  characterized  by  the  softness 
typical  of  lipomata.  It  is  prone  to  recur,  and  apparently  produces  a 
cachexia  almost  as  profound  as  that  of  malignant  growth. 

Diagnosis  can  be  made  only  by  operation. 


THE  BONES  129 

Lipomata  growing  from  the  bones  of  the  head  and  spine  are  usually 
the  remains  of  cured  meningocele. 

The  bone  lipoma  of  the  adult  is  characterized  by  the  softness,  lobula- 
tion, slow  growth,  and  absence  of  subjective  symptoms  characteristic  of 
this  form  of  tumor. 

Sarcoma. — Sarcoma  is  the  commonest  bone  tumor.  It  is  usually  single, 
developing  in  youth  and  early  manhood.  It  is  observed  in  infancy, 
and  may  be  prenatal.  It  is  usually  most  malignant  in  young  subjects. 
The  favorite  seats  are  the  jaw,  femur,  tibia,  radius,  and  humerus.  The 
epiphyseal  extremities  of  the  long  bones,  particularly  those  about  the 
knee,  are  the  seats  of  predilection. 

The  diagnosis  of  sarcoma  is  based  on  pain,  tumor,  and  the  a;-ray 
findings  (pp.  41  and  43).  Pain  is  fixed,  persistent,  often  referred  to  the 
neighboring  joint,  and  is  generally  treated  as  rheumatic.  These  symp- 
toms may  precede  the  development  of  tumor  by  weeks  or  months. 
The  tumor  may  be  globular  or  fusiform,  hard  or  soft,  and  in  the  case 
of  central  sarcomata,  often  gives  an  egg-shell  crackling  which  in  itself 
is  not  diagnostic  of  malignancy.  In  highly  vascular  cases  there  is 
both  pulsation  and  bruit.  In  rapidly  growing  cases  there  is  a  distinct 
rise  in  temperature,  both  local  and  general.  Fracture  is  common  in 
central  sarcomata,  and  may  be  the  first  pronounced  symptom  to  call 
attention  to  disease  of  the  bone.  In  periosteal  sarcomata,  tumor  may  be 
observed  early.  It  does  not  encircle  the  bone,  has  fairly  abrupt  margins, 
and  is  more  regular  in  outline  and  rapid  in  development  than  either 
osteoma  or  chondroma. 

Sarcoma  of  the  bone  is  usually  central,  and,  if  of  the  giant-cell  type 
(common),  is  relatively  benign;  exceptionally  it  gives  metastases  and 
recurs  after  thorough  operations.  Central  spindle-cell  sarcoma  (rare) 
is  also  of  relative  benignancy.  The  central  round-cell  sarcoma  is  highly 
malignant,  as  are  the  periosteal  sarcomata. 

The  diagnosis  of  sarcoma  may  be  suggested  by  the  ic-rays,  but  can  be 
made  certainly  only  by  excision  and  microscopic  examination,  the  latter 
facilitated  by  a  freezing  microtome,  made  at  the  time  of  operation,  since 
the  form  of  intervention  depends  upon  the  type  of  growth.  The  macro- 
scopic appearance  of  some  of  these  tumors  is  sufficiently  characteristic 
of  relative  benignancy  to  enable  a  probably  wise  decision  to  be  made 
between  local  excision  and  amputation  wide  of  the  disease.  The  giant- 
cell  sarcoma  is  usually  completely  enclosed  in  a  capsule  of  bone,  on  break- 
ing through  which  there  is  exposed  a  vascular  pulp  which  bleeds  furiously. 
The  limitation  of  the  more  malignant  growths  is  less  distinct. 

Myeloma.^ — Myeloma  exhibits  an  early  predilection  for  bones  of  the 
thorax,  including  the  vertebrae.  It  is  characterized  by  the  multiplicity 
of  its  lesions  and  albumosuria.  Distinction  from  sarcoma  may  be  made 
clinically  on  this  basis. 

Endothelioma. — Endothelioma  presents  the  characteristics  of  central 
sarcoma.     Nor  can  a  distinction  be  made  excepting  by  microscopic 
examination.     The  affection  is  one  of  middle  age,  and  is  likely  to  be 
multiple. 
9 


130  THE  BONES  AND  JOINTS 

Carcinoma. — Carcinoma  of  the  bones  is  always  secondary,  usually 
to  cancer  of  the  breast,  prostate,  or  thyroid.  These  metastases  may 
occur,  particularly  in  the  case  of  the  prostate  or  the  thyroid,  before 
the  primal  focus  has  reached  sufficient  dimensions  to  excite  clinical 
symptoms. 

Diagnosis  is  based  on  pain  and  swelling;  there  is  often  spontaneous 
fracture.  Thyroid  metastasis  is  commonly  observed  in  the  sternum, 
bones  of  the  skull,  the  humerus,  and  the  vertebrae.  The  prostatic 
metastasis  is  commonly  manifest  in  the  vertebrae. 

The  bone  manifestations  of  hypernephroma  are  those  of  malignant 
disease.     The  distinction  must  be  made  with  the  microscope. 

Bone  Cysts. — Bone  cysts  (rare)  develop  in  the  shafts  of  long  bones 
during  youth  near  the  epiphyseal  line,  particularly  in  the  tibia,  femur,  and 
humerus.  They  are  characterized  by  a  tendency  to  spontaneous  fracture, 
often  by  pain  of  moderate  severity,  and  by  the  gradual  formation  of  a 
fusiform  tumor  made  up  of  a  single  fibrocartilaginous  sac  containing 
bloody  fluid,  surrounded  by  a  thin  cortex  and  normal  periosteum. 

The  diagnosis  is  based  upon  slow  growth  (months,  years),  the  a;-rays, 
and  by  incision. 

Multiple  bone  cysts  are  frequently  found  in  the  bones  of  osteomalacia, 
while  cystic  degeneration  is  common  in  sarcomata  and  enchondromata. 

Dentigerous  Cysts. — Dentigerous  cysts,  originating  in  the  jaws,  form 
slowly  growing  bone  swellings  extending  in  the  direction  of  the  outer 
surface  of  the  jaw,  occurring  in  young  adults  who  on  examination  show 
the  absence  of  a  tooth.  They  cannot  be  distinguished  clinically  from 
dermoid  cysts  nor,  excepting  by  operation,  from  sarcoma. 

Echinococcus  Cysts. — Echinococcus  cysts  are  rare,  and  can  be  diag- 
nosticated only  by  operation. 

Fibromata. — Fibromata  of  bone,  with  the  exception  of  certain  forms 
of  epulis  and  nasopharyngeal  growths,  are  rare.  The  latter  condition 
is  observed  mainly  in  young  men  under  twenty-five  years  of  age.  The 
slow  growth  and  dense  consistency  of  fibromata  are  thoroughly  character- 
istic, but  diagnosis  must  be  made  by  excision  and  microscopic  examina- 
tion, since  the  distinction  cannot  otherwise  be  made  from  fibrosar- 
coma. 

Fat  Embolism.- — Fat  embolism  is  an  occasional  complication  of  bone 
lesions  such  as  are  accompanied  by  extensive  crushing  of  the  medulla, 
as  in  fracture  of  the  lower  end  of  the  femur.  It  may  follow  operation 
upon  bone.  It  is  characterized  by  acute  edema  of  the  lungs,  coming  on 
suddenly  some  days  after  bone  injury.  Signalized  by  dyspnea,  often 
accompanied  by  coughing  up  of  blood-stained  serum  indicative  of  infarct, 
and  by  a  rapid,  labored  heart  action,  right-sided  dilatation  and  vertigo, 
apathy,  or  even  loss  of  consciousness  (Forgue).  The  diagnosis  is  based 
upon  the  sudden  onset  of  all  such  symptoms  following  bone  trauma  and 
the  finding  of  fat  in  the  urine  which  appears  on  its  surface  as  a  cloudy 
deposit  made  up  of  fat  globules,  which  may  be  demonstrated  by  staining 
with  osmic  acid. 


THE  JOINTS  131 


THE  JOINTS. 


Traumatism. — Contusion. — Contusion  may  be  from  direct  or  indirect 
violence.  In  the  latter  case  the  major  lesion  is  a  bruising  of  the 
articular  surfaces  often  associated  with  fracture;  in  the  former  case  the 
soft  parts  exhibit  the  major  evidences  of  traumatism. 

The  symptoms  of  joint  contusion  are:  tenderness  on  pressure  and 
motion,  severe  pain,  disability,  and  rapid  swelling  which,  if  the  joint  be 
accessible  to  palpation,  can  be  felt  to  be  mainly  intra-articular. 

Rapid  (minutes  or  hours)  swelling,  severe,  persistent  pain,  absolute 
disability,  excessive  tenderness,  are  presumptive  evidences  of  fracture. 

Rapid  and  extensive  effusion  into  a  joint  as  the  result  of  slight  contu- 
sion or  sprain  is  suggestive  of  hemophilia.  This  suggestion  becomes 
almost  a  certainty  if  there  is  but  slight  pain  and  disability,  the  major 
symptom  being  swelling  due  to  rapid  capsular  distention,  associated 
with  a  history  of  prolonged  bleeding  from  slight  wounds. 

The  diagnosis  of  joint  contusion  is  made  by  the  x-rays  and  by  prompt 
recovery  as  the  result  of  rest. 

Chronic  arthritis  following  contusion  is  an  expression  of  recurring 
trauma  from  hypertrophied  synovial  fringe,  loose  body,  fracture,  etc., 
or  of  the  localization  of  a  toxin  or  infection  at  a  point  of  lessened 
resistance  (gout,  rheumatism,  tuberculosis). 

Sprain. — ^This  implies  sudden  overstretching  of  periarticular  soft  parts, 
often  associated  with  a  tearing  away  of  bony  attachments  and  bruising 
of  the  joint  surfaces.  The  wrist  and  ankle  are  the  usual  seats.  It  is 
characterized  by  disability,  severe  pain,  swelling,  tenderness  most  marked 
at  the  seat  of  tear,  and  late  discoloration. 

Exaggeration  of  local  symptoms,  and  especially  their  persistence,  is 
presumptive  evidence  of  complicating  fracture  or  the  localizing  in  an 
area  of  lessened  resistance  of  systemic  toxemia  or  infection. 

Since  the  diagnosis  in  severe  cases  calls  for  the  elimination  of 
fissured  fracture,  this  usually  requires  the  help  of  the  a;-rays. 

Wounds  of  Joints. — ^The  diagnosis  is  usually  obvious  or  may  be  sug- 
gested by  escape  of  synovial  fluid. 

Punctured  wounds,  as  from  a  dirty  needle,  may  cause  a  serous  or  sero- 
fibrinous effusion,  characterized  by  distention  of  the  capsule,  tenderness 
and  limitation  of  motion,  or  the  most  virulent  type  of  purulent  arthritis. 

When  infection  has  taken  place,  this  may  remain  latent  until  the  second 
or  third  day  when  symptoms  of  acute  suppurative  inflammation,  both 
local  and  constitutional,  develop  rapidly.  In  hyperacute  cases  inflamma- 
tory symptoms  develop  within  twenty-four  hours.  This  is  particularly 
the  case  when  there  is  a  large  effusion  into  the  joint. 

Dislocation. — Dislocation,  rare  in  the  young  and  the  old,  may  be  trau- 
matic or  pathological.  The  latter  as  a  consequence  of  disease;  usually 
an  abundant  intra-articular  effusion,  extensive  bone  destruction,  or  both. 

The  diagnostic  features  of  traumatic  dislocations  are:  marked  defor- 
mity, usually  appreciable  on  inspection  and  palpation;  elastic  fixation; 


132  THE  BONES  AND  JOINTS 

alteration  of  the  axis  of  the  bone  luxated  in  relation  to  that  of  the  bone 
with  which  it  should  articulate,  and  either  lengthening  or  shortening.  In 
addition  the  symptoms  common  to  all  traumata  are  present,  i.  e.,  pain, 
swelling,  tenderness,  disability,  great  discoloration. 

On  palpation  the  articular  extremities  of  the  bone  can  usually  be  felt 
not  in  their  proper  relation  one  with  the  other.  This  in  the  case  of  deep 
joints  or  great  tenderness  and  swelling  may  not  always  be  easily  demon- 
strated. 

Distinction  from  contusion,  sprain,  and  fracture  is  made  by  the  x-tsljs 
and  examination  under  ether.  Elastic  rigidity  is  contrasted  with  the 
preternatural  mobility  of  fracture,  the  rounded  joint  ends  with  the 
jagged  ones  of  fracture,  the  deformity  is  of  the  joint  itself  and  not  simply 
near  it,  and  the  deformity,  reduced  with  difficulty  and  often  with  a 
sudden  jar  or  slip,  does  not  recur  immediately  on  removal  of  the  traction 
or  support. 

Complicating  fracture  in  or  near  the  joint  often  requires  the  x-vajs  for 
its  diagnosis.  Injuries  of  neighboring  nerves  and  vessels  should  be 
detected  at  the  time  of  first  examination. 

From  epiphyseal  separation,  dislocation  is  distinguished  by  the  fact 
that  the  epiphyseal  separation  is  an  affection  of  youth,  there  is  no  elastic 
fixation,  but  rather  preternatural  mobility,  the  deformity  is  easily  reduced, 
and  as  readily  recurs  on  removing  traction  or  support. 

Pathological  luxation  may  be  concealed  by  the  swelling  and  deformity 
incident  to  the  causative  lesion  (caries,  necrosis,  hydrops  or  rheumatoid 
arthritis). 

The  power  of  voluntary,  usually  incomplete,  luxation  is  sometimes 
seen  developed  to  an  extraordinary  degree,  and  is  due  to  the  unusual 
laxity  of  the  ligaments.  This  maneuver  is  commonly  dependent  upon 
long  practice. 

Congenital  luxation,  commonest  in  the  hip,  is  the  result  of  imperfect 
fetal  development,  and  is  often  combined  with  other  deformities.  It  is 
most  frequent  in  females,  is  usually  unilateral,  and  is  obvious  by  com- 
parison of  the  trochanters  of  the  two  sides.  When  bilateral  the  diagnosis 
may  necessitate  the  use  of  the  a:-rays. 

Arthritis. — Arthritis  may  be  traumatic  (a  single  severe  or  slight 
repeated  injury);  secondary  to  inflammation  of  neighboring  structures, 
particularly  the  epiphysis;  a  local  expression  of  systemic  infection 
or  toxemia  (rheumatism,  pyemia,  typhoid,  gonorrhea,  la  grippe,  gout, 
pneumonia,  tonsillitis,  any  focus  of  suppuration);  neuropathic  (tabes, 
syringomyelia,  peripheral  nerve  inflammation  or  injury);  or  incident  to 
the  nutritional  changes  of  arteriosclerosis  (senile  arthritis  deformans). 

In  its  clinical  manifestations  it  may  be  acute  or  chronic.  The  exudate 
may  be  serous,  fibrinous,  or  purulent. 

The  type  of  facute  serous  arthritis,  often  called  synovitis,  because  the 
synovia  exhibits  the  principal  lesions,  is  characterized  by  more  or  less 
abundant  effusion,  often  slightly  turbid  because  of  the  mixture  with 
endothelium  and  fibrin.  The  synovia  is  markedly  congested  and  often 
infiltrated  with  leukocytes  and  even  with  extravasated  blood.     There  is 


THE  JOINTS  133 

heat,  tenderness,  swelling,  and  fluctuation,  with  fixation  of  the  joint  in 
the  position  allowing  of  greatest  distention  (usually  slight  flexion),  great 
pain  on  motion,  rigidity  of  muscles,  and  usually  some  atrophy.  This 
type  of  arthritis  follows  traumatism,  either  from  external  violence,  in 
which  case  the  effusion  usually  contains  blood,  or  from  pinching  of  the 
articular  surfaces  incident  to  loose  bodies  in  the  joint.  It  is  also  the 
commonest  expression  of  systemic  infection,  particularly  of  that  form 
called  rheumatic  fever.  Typhoid,  la  grippe,  pneumonia,  gonorrhea,  even 
pyemia,  may  in  their  joint  expression  be  characterized  by  serous  effusion. 
Even  an  acute  juxta-articular  suppurative  osteomyelitis,  unless  the  pus 
breaks  directly  into  the  joint  cavity,  may  be  attended  simply  by  a  serous 
arthritis. 

The  fibrinous  exudate  is  characterized  by  the  same  symptoms;  the 
distention  of  the  joint  capsule  is  less  marked,  there  is  no  fluctuation 
even  in  accessible  joints,  but  the  periarticular  swelling  is  greater.  Pain 
is  more  intense,  fixation  and  muscular  atrophy  develop  rapidly,  and 
the  affection  runs  a  much  more  chronic  course,  frequently  resulting  in 
permanent  fixation. 

Traumatism  when  associated  with  intra-articular  bone  lesions  may  be 
characterized  by  a  fibrinous  exudate.  This  form  is  a  frequent  expression 
of  la  grippe  and  gonorrhea,  an  occasional  one  of  other  forms  of  infec- 
tion. 

Purulent  arthritis  commonly  follows  a  serous  effusion,  or  may  be  puru- 
lent from  the  first.  The  pain  is  intense,  the  muscular  fixation  absolute. 
The  periarticular  heat,  redness,  and  swelling  are  more  marked  and 
rapidly  progressive,  constitutional  symptoms  are  profoundly  septic,  and 
the  joint  structure  is  rapidly  destroyed. 

This  form  of  arthritis  is  usually  incident  to  an  infected  wound  or  is 
secondary  to  suppuration  of  structures  near  the  joint  (osteomyelitis, 
tenosynovitis). 

In  mild  cases,  and  this  is  particularly  true  of  the  acute  suppurative 
synovitis  of  small  children  and  of  the  suppurative  arthritis  secondary  to 
pyemia,  the  infection  remains  confined  to  the  joint,  and,  if  this  be  promptly 
drained,  joint  function  may  be  restored. 

It  is  an  occasional  local  expression  of  pyemia  and  exceptionally  one 
of  pneumonia  or  gonorrhea.  It  is  possible  in  any  form  of  infectious 
arthritis. 

The  diagnosis  is  based  upon  hyperacute  local  inflammatory  symptoms, 
with  rapid  and  progressive  involvement  of  the  soft  parts  and  the  consti- 
tutional symptoms  of  profound  sepsis  associated  with  polymorphonuclear 
leukocytosis. 

Acute  Traumatic  Arthritis. — Acute  traumatic  arthritis,  incident  to  con- 
tusion, wrench,  or  the  pinch  of  a  locked  loose  body,  attended  by  a  serous 
or  sanguinoserous  effusion,  is  characterized  by  fixation,  pain  on  joint 
palpation  and  movement,  and,  where  the  capsule  is  palpably  near  the 
surface,  fluctuating  swelling.  In  the  absence  of  bone  lesion,  repeated 
trauma,  or  gouty  or  rheumatic  diathesis  the  recovery  is  prompt  and 
complete. 


134  THE  BONES  AND  JOINTS 

Wounding  of  the  joint  may  lead  to  acute  suppurative  arthritis  charac- 
terized by  the  local  and  constitutional  symptoms  of  retained  pus. 

Acute  Rheumatic  Arthritis. — ^Acute  rheumatic  arthritis  is  a  local  ex- 
pression of  a  constitutional  toxemia  or  infection  which  begins  with  chill 
and  fever,  not  remittent,  accompanied  or  shortly  followed  by  pain, 
tenderness,  swelling,  fixation,  and  in  severe  cases,  heat  and  redness  of 
one  or  more  of  the  larger  joints. 

The  arthritis  is  usually  multiple  and  shifts  from  joint  to  joint,  though  it 
may  be  monarticular.  Acid  sweats  are  regarded  as  characteristic, 
and  endocarditis  is  such  a  frequent  complication  that  its  development 
is  of  diagnostic  value. 

In  children  the  onset  is  less  abrupt,  the  joint  symptoms  not  so  well 
marked,  and  the  inflammation  may  exhibit  little  tendency  to  flit  from 
joint  to  joint.     It  is  at  times  associated  with  tonsillitis. 

The  monarticular  type  of  rheumatic  arthritis  can  be  distinguished  from 
acute  suppurative  arthiitis  by  the  more  profound  sepsis  of  the  latter  con- 
dition and  the  rapid  progression  of  local  symptoms. 

Acute  Gouty  Arthritis. — Acute  gouty  arthritis  is  characterized  by  the 
suddenness  of  an  acute  attack,  particularly  of  the  metatarso-phalangeal 
joint  of  the  great  toe,  accompanied  by  rapid  swelling,  heat,  and  red- 
ness of  the  skin.  The  attacks  are  transitory  but  recurrent,  affect  the 
small  joints  by  preference,  are  unattended  by  pronounced  constitutional 
symptoms,  and  are  often  accompanied  by  palpable  urate  nodules  about 
joints  other  than  the  ones  acutely  inflamed. 

The  finding  of  glycocoU  in  the  urine  with  diminution  in  the  amount 
of  uric  acid  is  said  to  be  characteristic  (Hirschstein). 

Acute  Gonorrheal  Arthritis. — Acute  gonorrheal  arthritis,  either  mon- 
articular or  polyarticular,  affects  the  knee  by  preference.  The  ankle,  the 
shoulder,  the  wrist,  the  hip,  and  the  joints  of  the  fingers  and  toes  come 
next  in  order  of  frequency.  It  is  a  complication  of  posterior  urethritis, 
and  occurs  usually  after  the  third  week  of  disease. 

The  effusion  is  serous  or  fibrinous.  In  the  former  case  the  swelling 
is  confined  to  the  joint;  it  may  be  persistent  or  recurrent;  when  acces- 
sible, is  distinctly  fluctuating;  pain  and  disability  are  moderate. 

The  fibrinous  exudate  is  attended  by  severe  pain,  prompt  fixation, 
pronounced  peri-articular  swelhng  attended  by  heat  and  redness,  and 
rapid  muscular  atrophy. 

The  diagnosis  of  gonococcal  arthritis  is  made  by  finding  a  focus  of 
infection.  This  is  usually  in  the  glands  and  follicles  of  the  posterior 
urethra,  the  ampulla  of  the  vas  or  the  seminal  vesicles. 

Exceptionally  suppuration  due  to  mixed  infection  occurs  accompanied 
by  the  local  or  constitutional  symptoms  of  this  condition. 

The  polymorphonuclear  leukocytosis  and,  in  case  of  aspiration,  the 
examination  of  the  joint  contents  indicate  the  condition.  The  rapid 
progression  of  the  local  inflammatory  symptoms  in  suppurative  cases 
is  characteristic. 

From  gonorrheal  arthritis  the  rheumatic  form  is  distinguished  by  its 
more  acute  fever,  acid  sweats,  and  polyarticular  expression  in  larger 


THE  JOINTS  135 

joints.  Gonorrheal  arthritis  may  exhibit  the  same  features.  The 
differential  diagnosis  is  then  dependent  on  the  presence  of  a  focus  of 
gonococcal  infection  (urethra,  conjunctiva). 

Acute  Arthritis  Deformans. — Acute  arthritis  deformans,  observed  in 
the  badly  nourished,  particularly  in  overworked  and  inadequately  clad 
young  women,  is  characterized  by  fever  (exceptionally  none),  pulse 
hurry,  and  simultaneous  development  of  acute  inflammatory  symptoms 
in  a  number  of  joints,  both  large  and  small,  but  particularly  those  of  the 
fingers  and  toes.  In  one  form  of  the  affection,  usually  observed  in  children 
(Still's  disease),  there  is  enlargement  of  glands  into  which  the  inflamed 
joints  drain  and  tumefaction  of  the  spleen.  This  form  of  arthritis  does 
not  undergo  resolution,  but  persists  in  a  chronic  form,  often  with  acute 
exacerbations,  ultimately  (months  or  years)  causing  stiffening,  deformity, 
and  distortion. 

The  diagnosis  from  acute  rheumatic  arthritis  can  be  made  only  by  the 
persistence  of  the  inflammation. 

Typhoid  Arthritis. — Typhoid  arthritis  in  its  polyarticular  form  may 
closely  simulate  acute  rheumatic  arthritis.  It  usually  develops  during 
the  acute  or  subsiding  stage  of  the  fever;  or  not  until  a  late  period  of 
convalescence. 

In  its  monarticular  form  it  commonly  involves  the  hip,  resulting  in  a 
chronic  serous  effusion  which  may  be  so  great  as  to  cause  luxation.  The 
symptoms  of  arthritis  are  not  well  marked,  and,  if  the  affection  occurs 
during  the  period  of  profound  systemic  depression,  neither  pain,  tender- 
ness, limitation  of  motion,  nor  disability  may  be  noted.  The  swelling  is 
obscured  by  the  deep  position  of  the  joint. 

The  diagnosis  is  based  on  the  presence  of  an  arthritis  following  typhoid 
fever  and  not  accounted  for  on  other  grounds. 

Typhoid  arthritis  may  be  of  the  suppurative  type  incident  to  mixed 
infection. 

Scarlet  fever  arthritis  so  closely  simulates  the  rheumatic  form  of  the 
affection  that  in  the  absence  of  sore  throat,  of  rash  and  characteristic 
rapid  pulse,  diagnosis  cannot  be  made. 

Influenza  arthritis  closely  corresponds  to  that  complicating  gonorrhea 
in  both  symptomatology  and  development.  Its  diagnosis  is  dependent 
upon  its  association  with  influenza. 

Pneumococcic  arthritis  develops  in  from  two  to  fifteen  days  from  the 
onset  of  acute  pneumonia  (Cave).  Exceptionally  it  precedes  the  lung 
involvement  or  may  even  occur  independent  of  this  inflammation.  It 
usually  suppurates  and  is  attended  by  a  large  mortality,  due  probably  to 
the  major  disease. 

In  the  absence  of  lung  involvement  the  diagnosis  must  be  made  by 
microscopic  and  bacterial  examination  of  the  joint  contents.  This  is  not 
infallible. 

Acute  Tuberculous  Arthritis. — Tuberculous  arthritis  occasionally 
develops  in  the  acute  form.  The  diagnosis  can  be  made  only  by  micro- 
scopic examination  and  inoculation  of  the  joint  contents  into  susceptible 
9.nimals.     Estimation  of  the  opsonic  index  (less  than  0.8  or  more  than 


136  THE  BONES  AND  JOINTS 

1.2)  may  be  useful.     A  preceding  tuberculous  periarthritis  or  tubercu- 
lous lesions  elsewhere  are  suggestive. 

Acute  hemophilic  arthritis  is  characterized  by  pronounced  acute  joint 
effusion  without  adequate  cause,  attended  by  at  most  slightly  marked 
inflammatory  symptoms  and  followed  by  late  ecchymosis.  It  occurs  in 
young  subjects  who  in  most  cases  give  a  history  of  free  bleeding  from 
trivial  wounds,  and  more  than  one  joint  is  commonly  affected,  though 
not  synchronously. 

The  affection  is  recurrent  and  ultimately  results  in  pronounced  dis- 
ability and  extensive  deformity.  The  diagnosis  is  suggested  by  the 
characteristics  given,  but  is  usually  made  on  aspiration  of   the  joint. 

Acute  purulent  arthritis  of  infants,  from  the  first  to  the  fourth  year, 
is  common  in  the  hip,  shoulder,  and  elbow,  and  is  a  joint  expression  of 
neighboring  osteomyelitis. 

The  joint  effusion  may  be  serous;  this  can  be  determined  by  aspiration. 
It  is  usually  purulent,  and  is  indicated  by  an  increase  in  the  local  and 
constitutional  symptoms,  fixation  of  the  joint,  and  rapidly  progressing 
edematous  swelling  of  the  soft  parts  surrounding  it.  Unlike  purulent 
arthritis  at  a  later  age,  after  drainage  the  functional  prognosis  is 
good. 

Chronic  Arthritis. — Chronic  arthritis  incident  to  repeated  slight  trau- 
matism, sequent  to  an  acute  attack,  due  to  a  persistent  or  recurring 
infection  or  toxemia,  consequent  to  nerve  lesion,  or  secondary  to  arterio- 
sclerosis, is  characterized  by  muscle  atrophy,  partial  or  complete  fixation 
(exceptionally  preternatural  mobility),  and  deformity.  The  changes 
may  be  atrophic  or  hypertrophic  so  far  as  the  bone  and  cartilage  are 
concerned,  but  in  either  case  the  joint  capsule  is  greatly  thickened. 

Chronic  traumatic  arthritis,  when  it  follows  the  acute  form  of  this 
affection,  is  usually  incident  to  an  injury  to  ligament,  bone,  or  cartilage 
resulting  in  a  healing  which  puts  the  joint  at  a  mechanical  disadvantage 
when  it  is  used.  Such  an  arthritis  is  often  expressed  in  the  form  of  a 
serous  effusion  (hydrops)  which  may  be  persistent  or  subject  to  apparent 
cure  and  frequent  relapses.  In  the  latter  case,  particularly  if  the  relapses 
are  attended  by  subacute  or  acute  inflammatory  symptoms,  loose  body 
(joint  mouse),  displaced  cartilage  (knee,  jaw),  or  thickened  synovial 
fringe  should  be  suspected.  Slightly  traumatized  joints  are  susceptible 
attacks  of  gout,  rheumatism,  tuberculosis,  and  the  various  infections 
which  have  joint  manifestations. 

Chronic  arthritis  deformans  of  either  the  atrophic  (rheumatoid  arthritis) 
or  hypertrophic  (osteoarthritis)  type  may  follow  an  acute  attack  resem- 
bling inflammatory  rheumatism,  or  may  develop  insidiously  from  the  first. 
Swelling,  stiffness,  and  deformity  are  slowly  (years),  often  irregularly, 
progressive,  or  the  disease  may  be  arrested. 

The  affection  may  be  polyarticular  or  monarticular. 

The  former  variety  involves  the  joints  of  the  fingers  and  toes,  and 
exhibits  a  tendency  toward  centripetal  joint  extension.  Observed  in 
children  it  is  often  of  the  fibrinous  and  ankylosing  type,  with  an 
acute  onset. 

The  monarticular  form,  an  affection  of  the  elderly,  has  a  predilection 


THE  JOINTS  137 

for  large  joints,  particularly  the  kiiee  and  hip.  In  this  type  the  bone 
and  cartilage  proliferations  are  usually  pronounced.  Joint  grating, 
synovial  effusion,  and  loose  bodies  are  common  accompaniments. 

The  diagnosis  of  arthritis  deformans  is  based  upon  the  persistence  of 
joint  symptoms  and  the  gradual  development  of  permanent  lesions  either 
following  an  acute  arthritis  or  developing  gradually.  In  the  latter  case 
there  is  recurring  joint  stiffness,  at  first  intermittent,  and  usually  most 
marked  after  periods  of  disuse,  as  in  the  morning,  followed  by  gradual 
deformity,  limitation  of  motion,  and  muscular  atrophy.  Not  infrequently 
distortion  results  from  muscular  contracture,  cicatricial  contraction  of 
periarticular  structure,  or  alterations  in  the  conformation  of  the  ends  of 
the  bone. 

Bony  nodulations  of  the  interphalangeal  joints,  particularly  the 
distal  ones  (Heberden's  nodes),  are  regarded  as  especially  character- 
istic. They  may  remain  the  only  evidences  of  joint  involvement,  causing 
little  inconvenience  and  unattended  by  obvious  inflammation  or  deformity 
of  the  joints  near  which  they  are  placed  or  of  any  other  articulations. 
Similar  bony  outgrowths  are  observed  about  the  phalangeal  joints  after 
trauma.  The  nodular  deposits  of  gout,  if  deeply  placed,  cannot  be 
distinguished  by  palpation  from  these  nodes. 

Since  the  etiology  of  the  affection,  variously  termed  arthritis  deformans, 
chronic  rheumatoid  arthritis,  osteoarthritis,  nodular  rheumatism,  etc., 
is  entirely  unknown,  the  differential  diagnosis,  according  to  types  and 
names,  seems  unnecessary.  There  is  reason  to  suppose,  as  is  the  case 
with  acute  joint  affections,  that  these  chronic  lesions  are  secondary  to 
infection  or  toxemia,  nor  should  the  diagnosis  be  regarded  as  complete 
until  the  sources  of  possible  infection  or  of  auto-intoxication  are  elimi- 
nated. 

By  the  aid  of  the  x-vajs  the  type  of  joint  involvement,  i.  e.,  atrophic 
or  hypertrophic,  may  be  determined,  also  the  differential  diagnosis  of 
those  forms  of  obscure  etiology  from  those  which  are  known  to  be 
infectious,  particularly  from  tuberculous  arthritis. 

Chronic  gouty  arthritis,  usually  a  sequel  of  recurring  acute  attacks, 
corresponds  to  the  general  type  of  arthritis  deformans  in  that  the  joints 
of  the  toes  and  fingers,  later  those  more  centrally  placed,  are  involved  in 
a  deforming  and  crippling  arthritis.  Gout  is,  however,  characterized  by 
periarticular  deposits  of  uric  acid  (tophi),  which  may  also  be  found  in  the 
ear,  and  patients  thus  afflicted  usually  have  Bright's  disease  and  arterio- 
sclerosis. 

The  diagnosis  from  other  forms  of  osteoarthritis  is  based  upon  the 
presence  of  the  tophi. 

Chronic  tuberculous  arthritis  is  usually  an  affection  of  young  males  and 
frequently  follows  slight  trauma.  Its  characteristic  symptoms  are  fij^ation 
of  the  joint,  or  at  least  limitation  of  its  motion,  and  muscular  atrophy 
with  pain  which  is  often  referred. 

The  time  when  this  affection  should  be  diagnosticated  is  when  there  is 
little  or  no  effusion  into  the  joint,  no  blurring  of  its  outlines,  no  consti- 
tutional symptoms,  and  at  the  most  a  limitation  in  motion  and  conscious 
or  unconscious  saving  of  the  part,  some  tenderness,  and  muscular  atrophy. 


138  THE  BONES  AND  JOINTS 

A  chronic  monarticular  arthritis  of  a  child  is  usually  tuberculous. 
The  joints  of  election  are  those  of  the  spine,  hip,  knee,  ankle,  and  elbow. 

Since  the  tuberculous  affection  is  usually  primary  in  the  epiphysis, 
involving  the  joint  later,  the  ic-rays  will  often  detect  a  lesion  before  the 
joint  is  infected.  In  appropriate  cases  the  tuberculin  test  and  the 
opsonic  index  will  be  found  serviceable. 

Arthritis  deformans  in  its  monarticular  form  is  an  affection  of  the 
elderly,  the  slow  (years)  progression  of  which  is  characteristic;  still 
more  so  the  absorption  and  hyperplasia  of  the  bones  and  cartilages  as 
shown  by  the  ic-rays. 

The  symptoms  of  chronic  traumatic  arthritis  are  so  like  those  of  early 
tuberculous  arthritis  that  prompt  diagnosis  must  be  made  by  the  a;-rays 
or  aspiration  of  fluid  and  injection  into  susceptible  animals. 

Syphilitic  arthritis  is  usually  secondary  to  gummatous  osteomyelitis. 
In  its  development  it  corresponds  closely  to  a  local  tuberculosis.  Nor  in 
adults  does  it  conform  to  the  type  of  tertiary  lesions,  which  are  usually 
painless. 

In  children  hereditarily  syphilitic,  an  almost  painless  chronic  inflam- 
mation of  the  knee,  elbow,  hip,  or  shoulder,  characterized  by  a  non- 
sensitive  swelling  and  accompanied  by  marked  disability  is  a  common 
expression  of  the  constitutional  disease. 

A  preceding  history  of  syphilis,  other  signs  of  the  disease,  and,  before 
the  destructive  and  cicatricial  stage,  the  curative  effect  of  appropriate 
treatment  are  of  diagnostic  value. 

Neuropathic  arthritis  is  usually  secondary  to  tabes  or  syringomyelia. 
It  may  follow  trauma  or  complicate  neuritis. 

Tabetic  arthropathy  commonly  affects  the  knee,  the  hip,  and  the  ankle; 
exceptionally  it  involves  the  joints  of  the  upper  extremity.  There  is  an 
atrophic  and  a  hypertrophic  form.  Diagnosis  is  based  upon  the  absence 
of  pain  and  the  inadequacy  of  cause  for  an  abundant  exudate  or  a  greatly 
deformed  joint  which  may  be  preternaturally  mobile  or  dislocated. 
From  hemophilic  arthritis  the  affection  is  distinguished  by  the  associated 
symptoms  of  tabes. 

Syringomyelic  arthropathy  occurs  in  the  upper  extremities  of  men  of 
advanced  years.  The  progress  is  slower  than  in  tabes,  the  deformity  is 
pronounced,  even  monstrous,  osteophytes  being  common,  and  dislocation 
is  frequent.     Analgesia  is  a  prominent  symptom. 

Free  Bodies  in  the  Joint. — These  may  be  fibrinous,  fibrolipomatous, 
cartilaginous,  or  bony. 

Fibrinous  concretions,  the  result  of  previous  inflammation,  are  often 
multiple  and  individually  attain  considerable  size.  Exceptionally,  free 
bodies  are  found  in  healthy  joints.  Usually  in  those  which  have  been 
subject  to  chronic  inflammation.     The  knee  and  elbow  are  common  seats. 

The  affection  is  characterized  by  synovial  effusion,  thickened  capsule, 
and  the  detection  of  the  movable  body  by  palpation.  Mechanical  locking 
of  the  articulation  causes  recurring  attacks  of  sudden,  often  excruciating, 
pain  brought  on  by  certain  movements  of  the  joint,  accompanied  by 
fixation,  which  is  temporary,  and  is  followed  by  synovial  effusion. 


THE  JOINTS  139 

The  diagnosis  can  usually  be  confirmed  by  the  x-rays.  The  patient 
often  makes  it  himself. 

Joint  Neurosis. — Under  this  title,  termed  also  hysterical  joint,  are 
classed  affections  which,  though  mimicking  those  of  an  inflammatory 
nature,  are  found  on  attentive  and  repeated  examination  to  depart  from 
type.  The  knee,  hip,  and  shoulder  are  the  seats  of  election.  The  major 
complaint  is  usually  pain  associated  with  tenderness  and  at  times  surface 
heat  and  redness.  Slight  trauma  is  a  common  predisposing  factor.  In 
the  more  severe  forms  there  may  be  fixation,  atrophy,  and  contracture, 
associated  with  vasomotor  disturbances. 

Diagnosis  is  based  upon  the  negative  evidence  of  the  x-rays,  the  absence 
of  inflammatory  symptoms,  the  disappearance  of  contractures  under  an 
anesthetic,  variability  of  symptoms,  and  the  association  of  other  hys- 
terical phenomena. 

Lipoma  is  occasionally  observed  in  the  joint,  usually  attended  by  a 
moderate  degree  of  synovial  effusion  and  acting  as  a  loose  body.  The 
diagnosis  is  usually  made  by  excision. 


CHAPTER    XI. 

DISEASES  OF  THE  NERVOUS  SYSTEM. 
By  T.  H.  WEISENBURG,  M.D. 

In  this  chapter  will  be  discussed  those  neurological  affections  which 
are  either  amenable  to  surgical  treatment  or  in  which  such  procedure 
is  considered  justifiable.  The  general  principles  upon  which  neuro- 
logical diagnoses  are  based,  and  only  so  much  of  the  histology,  anatomy, 
physiology,  and  pathology  of  the  nervous  system  as  is  needful  for 
diagnostic  purpose  are  given 

PHYSIOLOGICAL  ANATOMY. 

The  nervous  system  consists  principally  of  the  brain  and  spinal  cord 
and  their  meninges,  of  a  peripheral  system  of  nerves  which  brings  the 
former  in  constant  communication  with  every  part  of  the  body,  and  of 
the  sympathetic  system  of  nerves  and  plexuses  which  serve  the  same 
purpose  for  the  internal  organs. 

The  brain  itself  consists  of  two  lateral  hemispheres  and  their  envelopes, 
an  after  part  which  is  called  the  cerebellum,  and  a  basal  portion  which 
connects  it  with  the  spinal  cord.  Closely  surrounding  and  adhering 
to  the  surface  of  the  brain  is  the  pia  mater,  this  dipping  into  the  various 
fissures.  The  other  parts  of  the  meninges,  that  is,  the  arachnoid  and  the 
dura,  adhere  so  closely  that  they  cannot  be  differentiated  (Fig.  42) . 

The  substance  of  the  brain  itself  consists  of  a  cortex  averaging  about 
one-quarter  inch  in  thickness,  in  which  are  situated  a  series  of  layers  of 
nerve  cells.  From  these  nerve  cells  arise  numerous  fibers  which  go  to 
other  parts  of  the  brain  and  into  the  spinal  cord.  That  part  of  the 
nervous  system  which  consists  of  nerve  cells  is  always  grayish  in  appear- 
ance, and  that  which  is  composed  of  nerve  fibers  is  of  white  color.  Be- 
sides the  accumulation  of  nerve  cells  which  is  found  in  the  periphery 
of  the  brain  tissue,  that  is,  the  cortex,  there  are  other  collections  of 
nerve  cells,  or  ganglia,  which  are  situated  within  the  hemispheres.  These 
ganglia  are  called  the  corpora  striata,  and  consist  of  the  caudate  nucleus, 
the  lenticular  nucleus,  and  the  optic  thalamus. 

The  convolutions  and  fissures  which  make  up  the  surface  of  the  brain 
underneath  which  the  cortex  lies  have  a  definite  and  systematic  arrange- 
ment, this  being  apparently  in  accordance  with  the  importance  of  the 
functions  concerned.  Thus,  embryologically  one  of  the  first  fissures  to 
be  marked  is  the  Sylvian  fissure,  around  this  being  the  important  motor 
and  sensory  centres,  and  the  nerve  fibers  which  are  in  relation  with  these 
functions  are  the  first  to  develop  or  obtain  their  myelin  sheaths  (Fig.  43). 


Pio.  42 


End  of  calloso- 
marginal  fissure. 


Parieto- 
occipital 
fissure. 


Ascending  fissure 
of  Sylvius.         / 
Fissure 
of  Sylvius 


Convolutions  and  sulci  on  the  exteral  surface  of  the  cerebral  hemisphere.      (Gray.) 

Fig.  43 


Convolutions  and  sulci  on  the  internal  surface  of  the  cerebral  hemispheres.     (Gray.) 


142  DISEASES  OF  THE  NERVOUS  SYSTEM 

Cortical  Localization. — As  a  result  of  embryological,  histological, 
experimental,  and  pathological  studies,  different  functions  have  been 
assigned  to  different  parts  of  the  cortex. 

Motor  Centres. — ^The  motor  functions  have  been  placed  directly  in 
front  of  the  central,  or  Rolandic,  fissure  in  the  precentral  convolution  on 
the  lateral  surface  of  the  brain  and  in  the  anterior  part  of  the  paracentral 
convolution  in  the  median  portion.  Every  movement  has  its  cortical 
representation,  the  head  centre  being  in  the  lowest  part  of  the  precentral 
convolution,  then  the  centres  for  the  face,  arm,  trunk,  abdomen,  and  leg 
coming  in  order,  that  for  the  leg  being  highest.  Thus  a  man  stands 
upside  down  in  his  motor  cortex.  Should  there  be  any  lesion  such  as 
would  irritate  any  of  these  centres,  for  instance  a  tumor  in  the  arm  area 
on  the  right  side  of  the  brain,  there  would  result  convulsive  movements 
of  the  left  upper  limb.  Should  this  lesion  destroy  this  centre,  paralysis 
of  the  limb  would  result.  It  must  be  remembered  that  while  the  centres 
concerned  in  the  innervation  of  structures  necessary  for  a  movement  are 
somewhat  distinct,  there  cannot  be  and  there  is  not  a  definite  division, 
and  that  the  nerve  cells  related  to  different  functions  are  in  apposition 
and  intermingle.  Thus  it  is  that  irritation  of  the  arm  area  by  an  electric 
current  or  by  a  tumor,  while  it  will  cause  a  convulsion  of  an  upper  limb, 
might  also  cause  movements  of  the  lower  limb. 

Sensory  Centres. — Directly  back  of  the  motor  centres,  behind  the  central 
fissure,  are  located  the  sensory  functions.  In  this  area  are  included  not 
only  the  postcentral,  but  also  the  superior  and  inferior  parietal  convolu- 
tions. In  the  postcentral  convolution  itself  are  placed  the  centres  for 
touch,  pain,  and  temperature,  that  is,  those  sensations  which  are  primary 
and  which  develop  first.  Their  localization  is  similar  and  in  apposition 
to  that  of  the  motor  functions ;  that  is,  those  which  are  concerned  in  the 
innervation  of  the  head  are  below,  and  of  the  leg  above.  In  the  parietal 
convolution  have  been  placed  the  centres  for  the  so-called  acquired 
sensations;  that  is,  the  senses  of  pressure,  movement,  position,  localiza- 
tion, and  stereognosis,  or  the  ability  to  recognize  objects  placed  in  the 
hand.  In  the  inferior  parietal  convolution  the  above  sensations  are 
localized  for  the  upper  limb  and  in  the  superior  parietal  convolution  for 
the  lower  limb.  Should  there  be  any  irritative  lesion,  for  instance,  in  the 
centre  for  sensation  in  the  upper  limb  on  the  right  side  of  the  brain,  there 
will  be  numbness  and  pain  localized  in  the  left  upper  limb,  these  sensa- 
tions being  analogous  to  the  convulsive  movements  which  result  from 
irritative  phenomena  of  the  motor  centres.  Destruction  of  any  sensory 
centre  will  also  in  a  similar  way  produce  loss  of  sensation  or  anesthesia 
(Fig.  44). 

Motor  Aphasia. — In  the  posterior  portion  of  the  third,  or  inferior,  frontal 
convolution  is  Broca's  convolution,  that  is,  the  gyrus  which  surrounds  the 
end  of  the  ascending  limb  of  the  fissure  of  Sylvius.  This  convolution  is 
adjacent  to  and  in  front  of  the  head  and  face  centre,  and  is  the  part  of  the 
brain  which  controls  motor  speech.  Should  there  be  a  disturbance  of 
this  centre,  the  patient  would  know  what  he  wanted  to  say,  would  under- 
stand everything  said  to  him,  but  would  not  be  able  to  talk  or  repeat 


PHYSIOLOGICAL  ANATOMY 


143 


words :  not  because  of  any  paralysis  of  the  muscles  which  are  concerned 
in  speech,  but  because  of  destruction  of  the  coordinating  centre  which 
controls  these  muscles.     This  is  motor  aphasia. 


Fig.   44 


CONCRtTE  CONCEPT 

Side  view  of  human  brain,  showing  localization  of  functions.     (Charles  K.  Mills.) 


Fig.  45 


View  of  the  mesial  surface  of  the  human  brain,  showing  localization  of  functions. 
(Charles  K.  Mills.) 


144  DISEASES  OF  THE  NERVOUS  SYSTEM 

As  most  of  us  are  right-handed,  the  speech  centre  is  locahzed  mostly 
in  the  left  cortex.  In  left-handed  persons,  however,  the  speech  centre 
is  on  the  right  side  of  the  brain.  Another  important  point  must  be 
remembered,  that  is,  what  act  controls  the  right-  or  left-hand edness  of 
the  individual.  Given  a  person  who  is  equally  skilful  with  either  hand, 
but  who  writes  with  the  right  hand,  such  a  person  will  be  preponderantly 
left-brained.  In  other  words,  the  function  of  writing,  which  is  perhaps 
the  highest  of  the  developmental  functions,  controls  largely  the  side  on 
which  the  speech  centre  is  principally  localized  (Fig.  45). 

Sensory  Aphasia. — In  the  middle  portion  of  the  left  first  and  second 
temporal  convolutions  in  right-handed  persons  is  the  centre  for  sensory 
speech.  A  lesion  of  this  part  will  cause  loss  of  memory  for  words  and  their 
meaning.  Such  a  person  would  be  unable  to  understand  what  is  said 
to  him,  and  he  would  be  able  to  talk,  because  his  motor  apparatus  is 
intact.   His  words,  however,  would  be  unintelligible  and  devoid  of  meaning. 

Word  and  Letter  Blindness. — Around  the  end  of  the  first  temporal 
convolution  is  what  is  called  the  angular  gyrus.  This  convolution  is 
directly  back  of  the  inferior  parietal,  or  sensory,  convolution  and  between 
it  and  the  visual  or  occipital  centres.  In  right-handed  persons  this  centre 
controls  the  ability  to  recognize  words,  letters,  and  figures.  In  a  destruc- 
tion of  this  area  the  patient  will  be  unable  to  write  his  name,  or,  in  fact, 
to  write  anything  or  to  read  words,  letters,  or  figures,  or  to  write  from 
dictation.  He  would,  however,  be  able  to  recognize  other  objects,  as 
pictures  or  music,  or  he  would  be  able  to  sketch  or  draw  or  recall  from 
memory  any  object  in  which  words,  letters,  or  figures  are  not  concerned. 
This  is  called  word,  letter,  or  figure  blindness. 

Visual  Centres. — ^The  centres  for  vision  are  localized  in  the  occipital 
convolutions,  especially  around  the  part  surrounding  the  calcarine  fissure 
or  the  cuneal  lobe.  The  parts  around  the  calcarine  fissure  are  concerned 
with  direct  vision,  while  the  other  portions  of  the  occipital  cortex  control 
peripheral  vision.  Should  there  be  a  lesion,  for  instance,  of  the  right 
calcarine  fissure,  there  would  be  loss  of  direct  vision  in  the  left  half  of 
each  central  visual  field.  In  a  lesion  of  the  occipital  lobe  of  the  right 
side  there  will  result  blindness  of  the  left  half  of  each  visual  field,  that  is, 
left  lateral  homon^Tnous  hemianopsia,  because  the  right  occipital  lobe 
supplies  the  right  half  of  each  retina,  this  controlling  the  left  field  of  vision. 
In  an  irritative  lesion  of  these  parts  there  will  result  flashes  of  light  in 
the  corresponding  fields. 

Psychical  Centres. — The  higher  psychical  functions  have  been  placed 
in  the  frontal  lobes,  and  especially  in  the  left.  In  any  lesion  of  these 
lobes  there  will  result  failure  of  memory,  loss  of  intelligence  and  of 
reasoning,  change  of  disposition  and  of  character.  It  must  be  remem- 
bered, however,  that  there  is  no  definite  mental  phenomenon  associated 
with  a  lesion  of  the  frontal  lobes,  and  failure  of  intelligence  is  not  diag- 
nostic of  such  lesion,  for  a  lesion  in  any  portion  of  the  brain  must  cause 
some  loss  of  intelligence,  for  every  portion  of  the  cortex  is  in  constant 
communication  with  every  other,  and  a  destruction  of  one  part  must  cause 
a  disturbance  of  the  integral  whole. 


PHYSIOLOGICAL  ANATOMY  145 

Subcortical  Centres. — Generally  speaking,  the  symptoms  of  a  tumor 
or  a  lesion  localized  underneath  the  cortex  will  depend  entirely  upon 
what  fibers  are  cut  off.  As  any  lesion  will  interfere  with  the  fibers 
related  to  more  than  one  function,  the  symptoms  will  never  be  clean  cut. 
For  instance,  a  tumor  localized  underneath  the  precentral  convolution 
will  not  only  give  motor  symptoms,  but  will  also  give  some  involvement 
of  sensation. 

While  it  is  acknowledged  that  in  the  cortex  are  localized  the  centres  for 
every  motion,  sensation,  and  special  act,  it  must  be  remembered  that 
this  is  so  only  so  far  as  simple  acts  like  lifting  a  finger  or  moving  a  limb 
are  concerned.  Where,  for  instance,  it  is  necessary  to  perform  a  complex 
act,  such  as  talking,  laughing,  crying,  eating,  or  swallowing,  there  must 
be  some  one  place  or  centre  which  coordinates  the  different  functions 
which  such  an  act  must  comprise.  The  speech  centres,  probably 
because  of  their  importance,  are  largely  localized  in  the  cortex,  but  they 
also  have  representation  in  the  subcortex.  As  to  where  the  centres  for 
laughing,  crying,  eating,  and  swallowing  are  we  are  not  certain,  but  we 
believe  that  they  must  be  localized  in  some  of  the  ganglia  in  the  subcortex, 
among  these  the  optic  thalamus  and  the  lenticular  and  the  caudate 
nucleus  probably  playing  the  most  important  role. 

Internal  Capsule. — ^The  internal  capsule  is  the  name  given  to  the 
pathway  of  fibers  which  come  from  the  cortex.  It  contains  an  anterior 
limb,  a  knee,  and  a  posterior  limb.  The  anterior  limb  transmits  the 
fibers  coming  from  the  frontal  to  the  opposing  cerebellar  lobe,  the  so- 
called  frontocerebellar  fibers.  The  knee  of  the  internal  capsule  trans- 
mits those  fibers  which  come  from  the  lowest  portion  of  the  precentral 
convolution,  i.  e.,  the  head  and  face  centres,  these  being  the  fibers 
which  go  to  the  nuclei  of  the  cranial  nerves  situated  in  the  crus, 
pons,  and  medulla,  i.  e.,  from  the  third  to  the  twelfth  nerves  inclusive 
(Fig.  46). 

The  posterior  limb  of  the  internal  capsule  transmits  in  its  anterior 
portion  the  motor  fibers,  in  its  middle  the  sensory,  and  in  its  posterior 
portion  the  fibers  which  come  from  the  occipital  or  visual  lobes.  Should 
there  be  a  lesion  of  the  posterior  limb  of  the  internal  capsule,  as,  for  in- 
stance, a  hemorrhage,  there  would  result  hemiplegia,  hemianesthesia,  and 
hemianopsia  on  the  other  side.  This  is  the  only  place  in  the  brain 
where  one  lesion  will  always  give  these  three  symptoms. 

The  Crus,  or  Cerebral  Peduncles. — ^The  cerebral  peduncles  are 
practically  the  continuations  of  the  posterior  limbs  of  the  internal  capsule 
and  transmit  the  fibers  for  motion  and  sensation,  thus  connecting  the 
brain  proper  with  the  brain  stem. 

The  nucleus  of  every  cranial  nerve  from  the  third  to  the  twelfth  inclu- 
sive receives  its  innervation  from  the  opposite  cortical  centre.  The 
first  and  second  cranial  nerves  do  not  enter  into  this,  as  they  are  really 
parts  of  the  brain. 

The  nucleus  of  the  third,  or  the  oculomotor,  nerve  is  situated  in  the 
posterior  portion  of  the  crus,  and  its  fibers  have  their  exit  at  the  foot  of 
the  cerebral  peduncles.  A  unilateral  lesion,  therefore,  of  the  cerebral 
10 


146 


DISEASES  OF  THE  NERVOUS  SYSTEM 
Fig.  46 


Hypoglossiis 


Horizontal  section  through  the  right  hemisphere.  B.  Kn,  knee  of  corpus  callosum;  Vh,  anterior 
horn  of  lateral  ventricle;  F^,  inferior  part  of  third  frontal  convolution;  I.  stric,  lenticulo-striate 
division  of  internal  capsule;  Knie.  ic,  knee  of  internal  capsule;  I.  optic,  lenticulo-optic  division  of 
internal  capsule;  Th,  optic  thalamus;  J,  island  of  Reil;  cl,  claustrum;  Operc,  operculum;  Tj,  first 
temporal  convolution;  r.  lie,  retrolenticular  region  of  internal  capsule;  C.  A.,  hippocampus  major; 
calc,  calcarine  fissure;  Hh,  posterior  horn  of  lateral  ventricle;  SS,  optic  radiation  of  Gratiolet;  T2, 
second  temporal  convolution;  Facialis,  position  in  capsule  of  motor  tract  to  the  face;  Hypoglossus, 
position  of  tract  to  the  tongue;  Arm,  position  of  tract  to  the  arm;  Bein,  position  of  tract  to  the  leg; 
S.  B.,  sensory  fibres;  S,  visual  tract;  A,  auditory  tract.     (M.  Allen  Starr,  after  von  Monakow.) 


PHYSIOLOGICAL  ANATOMY  147 

peduncle  would  always  give  oculomotor  palsy  on  the  same  side  with  the 
addition  of  a  paralysis  of  the  lower  part  of  the  face,  arm,  and  leg  on  the 
other  side  of  the  body. 

The  Pons. — In  the  pons  are  located  the  nuclei  for  the  fifth,  sixth, 
seventh,  and  part  of  that  of  the  eighth  cranial  nerve,  the  exits  of  these 
nerves  corresponding  in  order.  In  a  unilateral  lesion  of  the  upper  part 
of  the  pons  there  will  be  paralysis  of  the  fifth  nerve  on  the  same  side  with 
hemiplegia  of  the  opposite  side.  In  a  lesion  limited  to  the  lower  portion 
of  the  pons,  there  will  result  facial  palsy  on  the  same  side  and  paralysis  of 
the  arm  and  leg  only  on  the  other  side.  In  discussing  the  symptoms 
of  lesions  in  the  crus  and  pons,  it  has  been  assumed  that  these  are 
confined  to  the  anterior  portions  of  these  structures.  Should  the  lesion, 
however,  be  more  extensive,  there  would  necessarily  have  to  be  involve- 
ment of  the  sensory  fibres  which  are  localized  directly  back  of  the  motor, 
and  there  would  result  in  addition  sensory  symptoms  on  the  other  side. 

Paralysis  of  Associated  Ocular  Movement.— Should,  however,  the 
lesions  involve  the  median  portions  of  the  crus  and  pons,  there  would  be 
paralysis  of  associated  ocular  movement.  This  is  rather  difficult  to 
understand,  unless  it  is  remembered  that  it  is  impossible  to  move  one  eye 
without  the  other,  and  therefore  every  movement  of  the  eyeballs  must  be 
an  associated  movement.  When  we  look  to  the  right  we  use  not  only 
the  external  rectus  muscle  on  the  right  side,  but  we  also  use  the  left 
internal  rectus,  i.  e.,  we  are  receiving  innervation  from  the  nuclei  of  the 
sixth  and  third  cranial  nerves.  To  make  this  possible  there  must  be  a 
connection  between  these  nuclei,  and  this  is  accomplished  by  means  of 
the  posterior  longitudinal  bundle  which  is  located  in  the  posterior  and 
median  portion  of  the  crus  and  pons. 

In  looking  downward  we  use  not  only  the  muscles  which  are  innervated 
by  the  third,  but  also  those  which  are  innervated  by  both  fourth  cranial 
nerves.  In  looking  upward  we  use  only  the  muscles  which  receive 
innervation  from  both  oculomotor  nuclei.  We  see  then  that  there  must 
be  a  similar  connection  between  the  oculomotor  nuclei  and  between 
these  and  the  nuclei  of  the  fourth  nerves. 

Should  there  be  a  lesion,  for  instance,  in  the  lower  part  of  the  right 
side  of  the  pons,  cutting  off  the  posterior  longitudinal  bundle,  there  will 
be  inability  to  look  to  the  right,  and  a  similar  lesion  on  the  left  side 
will  cause  inability  to  look  to  the  left.  A  lesion  cutting  oflf  both  bundles 
will  cause  inability  to  look  to  the  right  or  left,  but  the  ability  to  look 
upward  and  downward  will  be  retained. 

In  a  lesion  of  the  upper  portion  of  the  pons  which  cuts  off  the  connec- 
tion between  the  third  and  fourth  nuclei  there  will  be  paralysis  of  asso- 
ciated movement  downward.  A  lesion  still  higher  up  will  cause  failure 
of  upward  movement. 

Partial  or  Total  Lesions  of  the  Medulla  Oblongata.— Partial  or 
total  lesions  of  the  medulla  oblongata  will  not  be  considered,  because 
hemorrhages  nearly  always  prove  immediately  fatal.  Neither  will 
lesions  of  the  quadrigeminal  and  other  structures,  because  of  our  lack 
of  definite  knowledge. 


148  DISEASES  OF  THE  NERVOUS  SYSTEM 

The  Cerebellum. — ^The  cerebellum  consists  of  a  middle  portion,  or 
the  vermis,  and  two  lateral  lobes.  It  is  connected  with  the  rest  of  the 
brain  by  three  processes  called  the  cerebellar  peduncles,  the  superior  or 
first  connecting  it  with  the  brain  proper,  the  middle  with  the  pons,  and 
the  inferior  with  the  medulla  and  spinal  cord.  In  the  middle  lobe  are 
situated  the  dentate  nucleus,  the  nucleus  fastigii,  and  the  nucleus  emboli- 
formis  and  globosus.  In  addition  certain  nuclei  situated  in  the  medulla 
oblongata  are  in  direct  communication  with  the  cerebellum,  and  should 
be  regarded  really  as  part  of  it.  These  include  Deiter's  nucleus,  the 
nucleus  vestibularis,  and  the  nucleus  magnoeellularis  substantia  reticu- 
laris, these  being  called  altogether  the  paracerebellar  nuclei. 

The  functions  of  the  cerebellum  are  not  definitely  known.  Experi- 
mental and  clinical  evidence  seems  to  show  that  lesions  in  any  portion 
will  produce  symptoms  of  incoordination  of  a  definite  character.  It 
has  recently  been  demonstrated  by  Sir  Victor  Horsley  that  the  cortex  of 
the  cerebellum  is  inexcitable,  but  that  irritation  of  the  intrinsic  cere- 
bellar nuclei  will  produce  conjugate  deviation  of  the  eyes  and  head  to 
the  same  side,  besides  flexion  of  the  homolateral  elbow,  and  that  deeper 
excitation  of  the  paracerebellar  region  will  produce  extension  of  the 
contralateral  elbow,  hyperextension  of  the  neck  and  trunk,  with  powerful 
extension  of  the  lower  limbs. 

It  is  probable  that  the  cerebellum  is  concerned  with  the  coordination 
of  every  voluntary  movement,  whether  this  be  of  the  limbs,  eyes,  or  of 
those  muscles  which  are  concerned  in  articulation,  eating,  or  swallowing. 
It  is  characteristic  of  this  incoordination  that  it  is  apparent  only  in  volun- 
tary movements  and  that  it  does  not  increase  when  the  object  is  attained 
or  when  the  eyes  are  shut  and  that  it  is  not  dependent  upon  any  dis- 
turbance of  peripheral  sensation. 

It  has  also  recently  been  held  that  lesions  of  the  cerebellum  will  pro- 
duce weakness  or  paresis  of  the  muscles  of  the  trunk  and  limbs,  but 
this  is  not  a  true  weakness  in  the  sense  that  it  is  dependent  upon  the 
motor  fibers.  Besides,  there  may  be  present  in  the  muscles  a  lack  of 
tone,  so  that  the  limbs  would  be  moved  like  a  flail.  If  the  lesion  is  in 
the  middle  lobe,  or  the  vermis,  the  symptoms  of  incoordination  are  most 
marked  and  will  involve  both  parts  of  the  body,  while  unilateral  lesions 
will,  of  course,  produce  preponderant  unilateral  ataxia  and  atonia. 

Whatever  symptoms  are  produced  by  lesions  of  the  cerebellum  or  by 
those  lesions  which  invade  the  cerebellum  by  pressure  are  dependent 
upon  this  disturbance  of  coordination.  This  is  apparent  in  every  move- 
ment, whether  it  be  in  the  gait,  station,  in  the  movement  of  a  limb  or 
limbs,  or  of  the  eyes,  or  of  those  muscles  which  are  concerned  in  eating, 
talking,  and  swallowing.  Other  localizing  symptoms  will  be  discussed 
under  the  head  of  cerebellar  tumors. 

The  Cranial  Nerves  (Fig.  47). — There  are  twelve  pairs  of  cranial 
nerves.  These  are  known  either  by  special  names  or  numerically.  The 
first  and  second,  or  the  olfactory  and  the  optic,  nerve  should  really  be 
considered  as  parts  of  the  brain  proper  and  not  as  distinct  cranial  nerves. 

The  centre  for  the  olfactory  nerve  is  not  definitely  known,  but  its  func- 


PHYSIOLOGICAL  ANATOMY 


149 


tion  is  concerned  with  smell,  the  loss  of  which  is  very  frequent  in  fracture 
of  the  base  of  the  skull. 

The  optic,  or  second,  nerve  is  the  nerve  of  vision.  From  the  orbits,  in 
their  course  backward,  the  optic  nerves  enter  into  and  form  the  optic 
chiasm  and  then  the  optic  tract,  and  from  here  the  visual  fibers  go  to  the 
primary  optic  centres,  these  constituting  the  anterior  corpora  quadri- 
gemina,  the  external  geniculate  body,  and  the  pulvinar,  or  posterior, 
portion  of  the  optic  thalamus.  Thence  the  fibers  pass  through|the 
extreme  posterior  portion  of  the  posterior  limb  of  the  internal  capsule 
to  the  occipital  lobe. 

Fig.  47 


GENU    OF 
ALLOSUM 


SYLVIAN 
FISSURE 
,\        ANTERIOR    PER- 
\AV     fOf^TED    SPACE 


INFUNDI- 
BULUM 

..POSTERIOR  PER- 
FORATED SPACE 
.CRUS    CEREBRI 


MIDDLE    CEREBEL- 
'      LAR    PEDUNCLE 


■  .-OBLONGATA 


—CEREBELLUM 


Under  surface  of  the  brain,  showing  the  superficial  origins  of  the  cranial  nerves.     The  Roman 
numerals  indicate  the  nerves.     (Testut.) 

It  must  be  remembered  that  the  visual  fibers  coming,  for  instance, 
from  the  right  occipital  lobe  innervate  the  right  half  of  each  retina  and 
thereby  supply  vision  to  the  left  half  of  each  visual  field.  A  lesion 
interrupting  the  fibers  coming  from  the  right  visual  centres  or  the 
occipital  lobe,  for  instance  either  in  the  extreme  posterior  portion  of  the 
posterior  limb  of  the  internal  capsule  or  in  the  so-called  primary  optic 


150 


DISEASES  OF  THE  NERVOUS  SYSTEM 


centres  or  in  the  optic  tract,  must  give  loss  of  half  vision  in  both  visual 
fields  on  the  other  side,  or  left  lateral  homonymous  hemianopsia.     From 


Fig.  48 


teft  Eye 


VisiudFiela 


The  visual  tract.  The  result  of  a  lesion  anywhere  between  the  optic  chiasm  and  the  cimeus  is  to 
produce  homonymous  hemianopsia.  H,  lesion  at  chiasm  causing  bilateral  temporal  hemianopsia; 
N,  lesion  at  chiasm  causing  unilateral  nasal  hemianopsia;  T,  lesion  at  chiasm  causing  imilateral 
temporal  hemianopsia;  SN,  substantia  nigra  of  crus;  L,  lemniscus  in  crus;  RN,  red  nucleus;  III, 
third  nerves. 

each  optic  tract  a  part  of  the  visual  fibers  innervate  the  temporal  part  of 
the  retina  on  the  same  side  and  the  nasal  of  the  other.     The  decussation 


PHYSIOLOGICAL  ANATOMY  151 

of  the  nasal  fibers  takes  place  in  the  centre  of  the  optic  chiasm.  A  lesion, 
therefore,  of  the  middle  of  the  optic  chiasm  will  give  loss  of  innervation 
to  the  nasal  part  of  each  retina  or  bitemporal  hemianopsia. 

A  lesion  interrupting  the  fibers  on  the  outer  side  of  the  optic  chiasm, 
as  for  instance  the  right,  will  cause  loss  of  innervation  to  the  right  tem- 
poral retina,  and  therefore  loss  of  the  nasal  field  of  vision  of  the  right  eye. 
A  bilateral  lesion  must  give  bilateral  loss  of  vision  of  the  nasal  fields,  or 
binasal  hemianopsia  (Fig.  48). 

A  lesion  destroying  the  whole  optic  chiasm,  as,  for  instance,  a  tumor 
of  the  hypophysis,  will  cause  loss  of  vision  in  both  eyes.  Destruction  of 
either  optic  nerve  will  necessarily  give  blindness  in  the  corresponding  eye. 

Choked  Disk,  or  Optic  Neuritis. — Whenever  there  occurs  increase  of 
intracranial  pressure,  whether  because  of  a  brain  tumor,  trauma,  or 
internal  hydrocephalus,  pressure  will  be  exerted  upon  the  optic  chiasm 
and  optic  nerves.  This  is  because  pressure  in  any  portion  of  the  brain 
will  result  in  a  heightened  tension  in  the  lateral  and  the  third  ventricle, 
the  latter  pressing  directly  upon  the  optic  chiasm  and  optic  nerves. 

In  every  choked  disk  there  must  be  some  inflammation  of  the  optic 
nerve,  or  optic  neuritis,  but  in  optic  neuritis  choked  disk  does  not  neces- 
sarily occur,  for  the  latter  is  distinctly  a  pressure  symptom.  When  the 
optic  nerve  is  pressed  upon  there  will  be  first  a  stasis  of  the  vessels,  this 
resulting  in  a  swelling  of  the  veins  which  is  so  severe  at  times  as  to  pro- 
duce hemorrhages.  There  will  also  be  retardation  of  the  arterial  flow 
causing  a  diminution  in  the  size  of  the  arteries.  Because  of  this  stasis 
there  will  result  an  edema,  which  will  produce  a  swelling  of  the  optic 
nerve  fibers  or  of  the  optic  nerve  head.  If  the  pressure  is  continued  the 
nerve  fibers  will  become  diseased,  resulting  in  impairment  of  vision.  This 
is  choked  disk.  If  the  pressure  is  continued  for  a  long  time  there  will 
necessarily  result  atrophy  of  the  optic  nerve  fibers. 

Pupils. — The  ciliary  muscles  react  to  two  forms  of  stimulus :  (1)  light, 
and  (2)  movement  of  the  eyeballs.  No  matter  what  the  stimulation, 
the  contraction  or  dilatation  of  the  pupil  is  performed  by  the  same  ciliary 
muscle,  but  the  innervation  differs.  The  ordinary  light  stimulation  is 
transmitted  by  means  of  the  optic  nerve  to  the  oculomotor  nucleus,  and 
from  here  the  impulse  to  the  ciliary  muscle  is  carried  by  the  oculomotor 
nerve.  This  is  the  light  reflex  arc,  and,  if  there  is  any  disturbance  any- 
where in  the  arc,  there  will  be  impairment  or  loss  of  the  reaction  of  the 
pupil  to  light.  The  flbers  which  are  concerned  with  the  reaction  of  the 
pupil  to  movement,  as,  for  instance,  in  convergence  and  divergence  and 
in  upward,  downward,  and  outward  movements,  have  probably  a  similar 
arc,  with  the  addition  that  they  are  in  connection  with  the  nuclei  of  the 
muscles  necessary  to  perform  the  given  ocular  movement. 

There  is  no  subject  of  which  we  have  a  less  definite  knowledge  than 
this,  and  it  is  a  safe  rule  when  considering  symptoms  of  brain  lesion  to 
pay  no  attention  whatever  to  the  condition  of  the  pupils. 

The  oculomotor,  or  third,  nerve  supplies  the  orbicularis  palpebrarum 
and  all  the  muscles  of  the  eyeball  with  the  exception  of  the  superior 
oblique  and  the  external  rectus.      A  total  paralysis  of  this  nerve  will 


152  DISEASES  OF  THE  NERVOUS  SYSTEM 

cause  ptosis  of  the  upper  lid,  outward  deviation  of  the  eye,  and  enlarged 
pupil,  with  inability  to  move  the  eye  in  any  but  the  outward  direction.  It 
is  possible  to  have  a  partial  involvement  of  the  oculomotor  nerve.  A  total 
or  partial  oculomotor  palsy  is  nearly  always  indicative  of  basal  syphilis. 

Paralysis  of  the  trochlear,  or  fourth,  nerve  is  an  extremely  rare  condition 
and  hardly  ever  occurs  alone,  but  is  generally  found  in  association  with 
palsies  of  the  other  ocular  muscles.  This  nerve  supplies  the  superior 
oblique  muscle  which  rotates  the  eye  downward  and  outward.  Basal 
syphilis  is  nearly  always  the  cause  of  the  paralysis. 

The  trigeminus,  or  fifth,  nerve  has  both  a  sensory  and  a  motor  function, 
but  is  mostly  sensory.  The  motor  part  supplies  the  muscles  of  mastica- 
tion. The  sensory  division  supplies  sensation  for  the  face,  eye,  nose,  jaws, 
teeth,  palate,  and  pharynx,  and  also  the  anterior  two-thirds  of  the  tongue. 

In  paralysis  of  the  motor  fifth  there  will  be  inability  to  chew  on  the  side 
of  the  paralysis,  the  contraction  of  the  masseter  muscle  will  be  weak,  and 
the  jaw  will  deviate  toward  the  affected  side.  In  an  irritating  lesion  of 
the  sensory  part  of  the  fifth  nerve  there  will  be  pain  either  in  its  whole 
distribution  or  in  a  subdivision  of  the  nerve,  i.  e.,  the  supra-orbital, 
infra-orbital  or  mental.  If  the  nerve  is  cut,  or  if  the  lesion  is  destructive, 
there  will  be  anesthesia  in  the  related  parts. 

The  ahducens,  or  sixth,  nerve  supplies  the  external  rectus  muscle,  which 
pulls  the  eye  outward.  Temporary  or  permanent  paralysis  is  a  very 
frequent  and  early  symptom  in  basal  syphilis  and  in  brain  tumors. 

The  facial,  or  seventh,  nerve  supplies  the  muscles  of  the  face,  including 
the  buccinator.  Paralysis  causes  inability  to  elevate  the  brow,  shut  the 
eye,  or  elevate  the  corner  of  the  mouth  on  the  involved  side,  with  the 
addition  of  lacrymation  in  the  involved  eye.  Palsy  occurs  in  basal 
syphilis,  but  not  so  commonly  as  in  the  sixth  nerve. 

The  auditory,  or  eighth,  nerve  has  two  divisions,  the  cochlear,  which 
is  the  nerve  of  hearing,  and  the  vestibular,  which  is  concerned  with 
coordination.  Basal  syphilis  or  tumors  are  the  most  frequent  cause  of 
unilateral  deafness. 

Meniere's  disease  is  the  name  given  to  a  symptom-complex  which 
generally  occurs  in  the  latter  end  of  life,  and,  as  a  rule,  begins  with 
unilateral  noises  in  the  ear,  accompanied  by  some  dizziness.  These 
first  come  on  at  intervals;  gradually  the  tinnitus  increases,  the  noises 
sometimes  resembling  the  shrieking  of  a  whistle,  becomes  bilateral 
and  is  accompanied  by  excessive  vertigo,  which,  as  a  rule,  terminates 
in  nausea  and  vomiting.  There  is  progressive  loss  of  hearing.  The 
tinnitus,  vertigo,  and  deafness  become  constant,  sometimes  preventing 
the  patient  from  assuming  an  erect  posture.  Rarely,  when  the  deaf- 
ness becomes  complete,  the  vertigo  and  tinnitus  cease.  It  is  supposed 
that  this  symptom-complex  is  due  to  a  disease  of  the  terminal  filaments 
of  the  vestibular  nerve  in  the  labyrinth,  and  there  may  also  be  disease 
of  the  semicircular  canals. 

The  glossopharyngeal,  or  ninth,  nerve  supplies  sensation  for  the  pos- 
terior third  of  the  tongue  and  the  pharynx,  and  also  motion  for  some 
of  the  palatal  and  pharyngeal  muscles. 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES  153 

The  pneumogastric,  or  tenth,  nerve  supplies  the  heart,  lungs,  abdominal 
viscera,  and  the  pharyngeal  and  laryngeal  muscles. 

The  spinal  accessory,  or  eleventh,  nerve  besides  innervating  the  trape- 
zius muscle  helps  to  innervate  the  same  structures  that  the  tenth  nerve 
does.  Isolated  paralysis  of  any  of  the  above  three  nerves  is  most 
unusual. 

The  hypoglossal,  or  twelfth,  nerve  supplies  motion  to  the  tongue.  In 
cases  of  paralysis  the  tongue  will  be  protruded  to  the  corresponding 
side  and,  when  in  the  mouth,  will  deviate  to  the  opposite  side.  Isolated 
lesions  are  very  uncommon. 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES. 

Certain  general  symptoms  may  be  present  in  any  disease  of  the  brain 
or  its  meninges,  the  degree  and  number  of  these  depending  upon  the 
nature,  extent,  and  location  of  the  lesion.  They  are  headache,  nausea, 
vomiting,  vertigo  or  dizziness,  disturbances  in  motility,  such  as  tremors, 
convulsions,  general  or  focal  in  type,  partial  or  total  paralysis,  disorders 
of  sensation  and  disturbances  of  vision  or  of  the  other  special  senses, 
and  lastly  alterations  in  mentality. 

Headache. — Headache  as  a  result  of  any  cerebral  lesion  is  nearly  al- 
ways due  either  to  an  irritation  of  the  dura  or  an  increase  of  intracranial 
pressure  which  causes  tension  of  the  dura.  The  meninges  are  inner- 
vated by  the  sensory  portion  of  the  fifth  nerve,  hence,  diseases  of  this 
must  cause  pain.  At  times  the  headache  is  localized  to  the  place 
of  direct  irritation,  but,  as  a  rule,  it  is  general.  The  pain  is  usually 
severe  and  constant  and  is  difficult  to  relieve  by  medication,  and  vomit- 
ing does  not  lessen  its  intensity. 

Nausea  and  Vomiting. — The  nausea  and  vomiting  which  are  present  in 
diseases  of  the  brain  are  generally  indicative  of  intracranial  pressure,  for 
they  are  not  present  unless  such  be  the  case.  They  are  probably  due  to 
an  irritation  of  the  ninth  and  tenth  nerves.  The  nausea  may  appear  in  the 
morning  or  at  any  time  and  may  be  accompanied  by  vomiting,  but  the 
latter,  as  a  rule,  does  not  relieve  the  nausea  or  the  accompanying  headache. 
The  vomiting  is  generally  projectile  in  character  and  comes  on  without 
warning.  These  symptoms  are  generally  indicative  of  brain  tumor.  A 
greater  amount  of  nausea  and  vomiting  is  present  in  cerebellar  lesions 
because  pressure  is  more  direct  upon  the  ninth  and  tenth  nerves. 

Vertigo,  or  Dizziness. — Vertigo,  or  dizziness,  is  also  considered  a  pressure 
symptom  in  diseases  of  the  brain.  The  dizziness  may  be  objective  or 
subjective,  i.  e.,  the  patient  may  either  see  objects  move  before  him  or  he 
may  have  a  sensation  that  he  moves  himself.  In  cerebral  tumors  this 
symptom  is  not  very  common,  but  in  cerebellar  lesions  vertigo  appears 
early  and  is  marked  and  persistent.  It  is  probably  due  to  pressure 
which  is  exerted  on  the  vestibular  division  of  the  eighth  nerve. 

Disturbances  in  motility  do  not  occur  unless  there  is  an  involvement 
either  of  the  cortical  motor  centres  or  of  the  fibers  coming  from  them. 


154  DISEASES  OF  THE  NERVOUS  SYSTEM 

Because  of  the  readiness  with  which  motor  symptoms  are  detected,  they 
are  more  quickly  appreciated  than  other  symptoms.  They  may  consist 
of  tremors,  forced  movements,  convulsions,  either  general  or  focal,  and 
partial  or  total  paralysis. 

Tremors. — ^These  may  be  coarse  or  fine.  Coarse  tremors  do  not 
result  from  surgical  brain  lesions,  and  are  usually  indicative  of  paralysis 
agitans,  multiple  sclerosis,  or  of  some  functional  disturbance.  Under 
fine  tremors  we  may  consider  fibrillary  twitchings.  These  are  always 
indicative  of  a  slow  and  progressive  degeneration  of  nuclear  cells. 

Forced  Movements. — Under  this  will  be  discussed  athetosis  or  athe- 
toid  movements.  These  may  be  present  in  the  face  or  in  all  of  the  limbs, 
or  in  any  one  of  the  limbs  or  face,  and  are  always  indicative  of  a  lesion 
of  the  motor  columns  either  at  infancy  or  birth.  The  athetoid  move- 
ment is  slow,  twisting,  and  constant. 

Convulsions. — ^These  are  characterized  by  spasmodic  movements  of  a 
part  of  a  limb,  a  whole  limb,  one-half  of  the  body,  or  of  the  whole  body, 
and  may  be  accompanied  by  loss  or  impairment  of  consciousness.  If  the 
convulsive  movement  is  limited  to  a  part  of  a  limb,  or  a  limb,  or  one-half 
of  the  body,  and  if  it  begins  always  in  the  same  muscles,  it  is  called  a 
focal,  or  Jacksonittii,  convulsion,  and  is  nearly  always  indicative  of  an 
irritative  lesion  in  the  motor  cortex.  In  Jacksonian  convulsions,  or 
epilepsy,  the  spasms  come  on  quickly  and  may  last  from  a  few  seconds 
to  several  minutes,  are  generally  clonic  in  type,  and,  as  a  rule,  are  not 
accompanied  by  unconsciousness. 

It  is  of  the  utmost  importance  to  see  where  a  Jacksonian  convulsion 
begins,  what  muscles  or  movements  it  involves,  and  their  succession. 
Supposing,  for  instance,  twitchings  began  in  the  fingers  of  the  right  hand, 
and  from  here  the  movement  extended  into  the  muscles  of  the  forearm, 
arm,  and  shoulder,  and  then  into  the  muscles  of  the  face.  This  would  be 
indicative  of  a  lesion  in  the  left  motor  cortex,  probably  extending  from 
the  hand  to  the  face  centre,  i.  e.,  from  the  middle  to  the  lower  portion  of 
the  precentral  convolution.  Should,  however,  the  convulsion  involve  the 
leg  instead  of  the  face,  it  would  indicate  that  the  lesion  extends  from 
the  middle  of  the  precentral  convolution  upward  or  to  the  leg  centre. 
These  facts  are  of  the  utmost  importance  when  surgical  procedures  are 
considered,  for  upon  their  correct  observation  will  rest  the  selection  of 
the  seat  of  operation. 

Epilepsy. — 'General  convulsions  are  nearly  always  indicative  of  epilepsy. 
This  disease  is  probably  due  to  maldevelopment  of  the  brain,  and  the 
spasms  in  the  large  majority  of  cases  first  appear  in  infancy.  Only  rarely 
do  they  appear  after  the  twentieth  year.  One  of  the  frequent  causes 
is  injury  to  the  head  very  early  in  life,  and  less  frequently  does  it  follow 
injury  to  the  head  in  adults.  The  cardinal  symptom  of  epilepsy  is  loss 
of  consciousness. 

There  are  three  types  of  attacks :  First,  major  epilepsy,  or  grand  mal; 
second,  minor  epilepsy,  or  petit  mal;  and  third,  psychic  epilepsy. 

In  major  epilepsy,  or  grand  mal,  there  may  or  may  not  be  an  aura. 
This  may  be  either  a  feeling  of  numbness  which  ascends  from  the  fingers 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES  155 

to  the  shoulder,  or  starts  from  the  stomaeh  and  goes  to  the  neck.  An 
aura  may  consist  in  disturbances  of  any  of  the  special  senses,  or  the 
patient  may  have  a  feeling  that  something  is  going  to  happen.  This 
aura  may  last  a  second,  a  few  seconds,  or  a  minute  or  longer,  and  is 
followed,  as  a  rule,  by  a  cry,  the  so-called  epileptic  cry,  and  the  patient 
falls  to  the  ground  unconscious.  The  body  then  becomes  rigid,  the 
head  may  bend  backward,  the  hands  are  clinched,  the  face  is  blue  or 
livid,  the  eyes  may  roll  in  any  direction,  and  the  teeth  are  clinched. 
Generally  the  patient  bites  his  tongue  and  froths  at  the  mouth.  This 
tonic  condition  may  last  from  a  few  seconds  to  several  minutes,  and  is 
succeeded  by  clonic  or  intermittent  movements  which  may  last  also  from 
a  second  to  several  minutes.  Relaxation  then  follows,  and  the  patient 
may  rally  from  the  attack  immediately  or  may  not  do  so  for  several  hours 
or  longer.  The  patient  generally  feels  weak  and  exhausted  afterward. 
Because  of  the  contraction  of  the  abdominal  muscles  on  the  bladder 
walls  there  is  usually  some  dribbling  of  urine. 

The  above  description  is  that  of  a  typical  attack  of  major  epilepsy. 
There  are,  of  course,  variations  of  this,  some  attacks  being  more  severe 
than  others.  As  a  rule,  these  convulsions  occur  intermittently,  some- 
times daily  or  oftener,  or  every  week  or  month;  but  if  a  number  of  attacks 
come  on  one  after  another  the  condition  is  known  as  status  epilepticus. 

By  minor  epilepsy,  or  petit  mal,  is  meant  a  condition  in  which  the  patient 
has  only  very  small  movements,  which  may  consist  of  the  twitching  of 
an  eyelid  or  movement  of  an  eye,  or  movements  of  the  jaw  or  tongue  or 
of  any  of  the  limbs;  but  the  important  point  is  that  there  is  always 
momentary  loss  of  consciousness. 

By  psychic  epilepsy  is  meant  a  condition  in  which  there  is  loss  of 
consciousness,  but  in  which  no  movements  occur.  There  are  of  course 
variations  of  this,  and  there  may  be  conditions  in  which  the  patient  is  in  a 
semistuporous  or  somnambulistic  condition,  and  performs  automatic 
movements  or  does  reasonable  things,  after  which  there  is  no  recol- 
lection of  what  has  happend.  As  a  rule,  however,  these  attacks  last 
only  a  few  seconds.  In  association  with  this  there  are  always  attacks 
of  grand  mal  or  petit  mal. 

Partial  or  Total  Paralysis. — It  must  be  borne  in  mind  that  in  the  motor 
cortex  are  represented  the  centres  for  movement,  and,  if  these  are  destroyed, 
paralysis  of  movement  will  occur,  the  extent  and  completeness  depend- 
ing upon  the  centres  destroyed.  Paralysis  of  one  limb,  the  result  of  a 
cortical  lesion,  is  very  unusual,  and,  if  present,  is  always  due  to  a  small 
tumor  or  more  probably  an  injury.  If  the  whole  motor  cortex  is  destroyed, 
hemiplegia  will  result. 

Reflexes. — Every  reflex  has  its  physiological  arc,  this  consisting  of  a  sen- 
sory impression,  a  centre,  and  a  motor  response.  The  simplest  example 
is  the  knee,  or  patellar,  jerk,  in  which,  after  tapping  the  patellar  tendon, 
the  impulse  is  carried  by  the  sensory  nerves  and  posterior  roots  to  the  cells 
of  the  anterior  horn  in  the  second,  third,  and  fourth  lumbar  segments, 
and  from  here  the  motor  response  is  transmitted  by  the  anterior  roots 
and  the  peripheral  motor  nerves.     If  there  is  a  lesion  in  any  portion  of 


156  DISEASES  OF  THE  NERVOUS  SYSTEM 

this  arc,  there  will  be  loss  of  the  reflex,  no  matter  what  the  condition  above 
in  the  spinal  cord  and  brain.  The  first  principle  then  in  the  attainment 
of  any  reflex  is  to  have  its  arc  intact  and  in  normal  condition.  Should, 
however,  there  be  a  lesion  in  any  portion  of  the  upper  motor  neuron  or 
system  anywhere  in  its  course,  and  the  relation  of  tone  is  disturbed,  there 
will  result  exaggeration  of  the  reflexes  because  of  loss  of  cerebral,  or  what 
has  often  been  called  inhibitory,  influence.  That  every  reflex  has  a  cerebral 
influence  is  proved  by  the  fact  that  if  there  is  a  complete  transverse  lesion, 
for  instance  in  one  segment  of  the  cervical  cord,  all  the  reflexes  below  are 
lost  even  though  the  arcs  are  intact. 

Reflexes  are  of  two  kinds:  First,  deep,  or  tendon,  and  second,  super- 
ficial, or  skin.     The  usual  tendon  reflexes  elicited  are: 

(a)  In  the  upper  limb :  The  biceps  and  triceps. 

The  biceps  reflex  is  obtained  by  having  the  patient  flex  the  forearm  on 
the  arm  at  a  right  angle.  The  thumb  of  one  hand  of  the  examiner  is 
then  placed  on  the  biceps  tendon.  Striking  the  thumb  with  the  per- 
cussion hammer  will  produce  flexion  of  the  forearm  upon  the  arm. 
The  centre  of  the  reflex  is  in  the  fifth  cervical  segment. 

Triceps  Reflex. — ^With  the  arm  in  the  same  position,  if  the  triceps 
tendon  is  struck  near  its  insertion  at  the  elbow,  extension  of  the  forearm 
on  the  arm  will  result.  The  spinal  centre  is  in  the  sixth  and  seventh 
cervical  segments. 

(h)  In  the  lower  limb : 

The  knee,  or  patellar,  jerk  is  best  obtained  by  crossing  one  leg  over  the 
other  and  striking  its  patellar  tendon  near  its  insertion.  A  forward 
movement  of  the  leg  will  result.  The  spinal  centre  is  in  the  second,  third, 
and  fourth  lumbar.  When  the  reflex  is  diminished  it  may  sometimes  be 
brought  out  by  reinforcement.  This  is  done  by  having  the  patient  lock 
his  hands  and  then  pull  them  apart  at  a  signal,  the  examiner  striking 
the  tendon  at  the  time  of  the  greatest  effort. 

The  Achilles  jerk  is  best  obtained  by  having  the  patient  kneel  on  a  chair 
and  then  tapping  the  Achilles  tendon  near  its  insertion  into  the  heel.  A 
flexion  of  the  foot  on  the  leg  will  result.  The  spinal  centre  is  in  the 
first  sacral. 

Ankle  and  Patellar  Clonus. — A  clonus  is  obtained  only  when  there  is 
an  exaggerated  tonicity,  and  always  indicates  a  lesion  of  the  motor,  or 
pyramidal,  tracts.  Ankle  clonus  is  obtained  by  first  flexing  the  leg  upon 
the  thigh.  With  one  hand  held  over  the  calf  of  the  leg,  the  other  holding 
the  foot,  a  sudden  flexion  of  the  foot  on  the  leg  is  made,  this  resulting 
in  to-and-fro  movements  at  the  ankle  which  are  regular  in  rhythm. 
Patellar  clo7ius:  With  the  leg  extended  on  the  thigh  the  patella  is  grasped 
between  the  thumb  and  the  forefinger  and  suddenly  brought  forward. 
Rhythmical  up-and-down  movement  constitutes  patellar  clonus. 

Biceps  and  triceps  clonus  is  sometimes  obtained  similarly  to  that  of 
the  ordinary  reflexes. 

Rarely  ankle  clonus  and  sometimes  patellar  clonus  can  be  obtained  in 
hysteria,  but  the  movements  are  not  regular  and  the  rhythm  is  influ- 
enced by  the  will. 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES 


157 


Skin,  or  Superficial,  Reflexes. — The  abdominal,  or  umbilical,  reflex  is 
obtained  by  stroking  upon  one  side  of  the  abdomen,  the  umbilicus 
approaching  to  the  side  of  the  irritation.  The  spinal  centre  is  in  the 
ninth,  tenth,  and  eleventh  thoracic  segments. 

The  cremasteric  reflex  is  obtained  by  irritating  the  inner  portion  of  the 
upper  thigh,  this  resulting  in  upward  movement  of  the  scrotum  on  that 
side.     The  spinal  centre  is  in  the  first  lumbar  segment. 

The  'plantar  reflex  is  obtained  by  irritating  the  plantar  surface  of  the  foot, 
flexion  of  the  toes  resulting.     The  spinal  centre  is  in  the  second  sacral. 

Fig.  49 


Contractures  following  hemiplegia.  Birth  palsy.  Patient  has  epilepsy.  Contractured  elbow, 
wrist,  and  digits.  Atrophic  (poorly  developed)  musculature.  Left  leg  similarly  but  less  markedly 
affected. 


Babinski's  reflex  is  obtained  by  irritating  the  plantar  surface  of  the  foot, 
extension  of  the  toes  resulting  Irritation  is  best  produced  with  a  match, 
which  should  first  be  carried  on  the  outer  part  of  the  foot  and  then  across. 
The  important  part  of  this  reflex  is  the  slow  extension  of  the  large  toe; 
the  movements  of  the  small  toes  may  be  disregarded.  It  is  also  advis- 
able to  first  grasp  the  foot  at  the  ankle  so  as  to  obviate  any  voluntary 
movement.  This  reflex  is  never  obtained  in  a  functional  condition,  and 
is  always  indicative  of  a  lesion  of  those  motor  fibers  which  are  in  relation 


158 


DISEASES  OF  THE  NERVOUS  SYSTEM 


with  the  lower  hmb.     A  lesion  of  the  motor  fibers  in  relation  with  the 
upper  limb  will  not  produce  this  reflex. 

Hemiplegia. — By  hemiplegia  is  meant  paralysis  of  an  arm,  leg,  and  the 
lower  part  of  the  face  on  the  same  side.  Such  a  patient  will  be  able  to 
wrinkle  the  brow  and  close  the  eyelids,  but  will  not  be  able  to  elevate 
the  corner  of  the  mouth  on  the  paralyzed  side.     In  every  hemiplegia 

Fig.  50 


Left  hemiplegia,  showing  drooping  of  tlie  left  side  of  the  face  and  flexor  contractures  in  the  left 
upper  limb,  differing  from  the  extensor  contractures  of  spinal-cord  disease. 


there  is  always  some  return  of  power,  and  it  is  a  rule  that  there  is  a  greater 
return  in  those  muscles  which  are  concerned  with  the  most  common 
movements.  In  the  upper  limbs,  the  flexors  being  stronger,  there  is  a 
greater  return  of  power  in  these  muscles,  this  resulting  in  a  flexor  con- 
tracture (Fig.  50).  In  the  lower  limbs,  the  extensors  being  the  stronger, 
the  contractures  are  always  in  extension.     Besides  the  loss  of  power, 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES  159 

with  its  subsequent  partial  return,  there  is  accompanying  stiffness,  or 
spasticity,  with  increase  of  all  of  the  tendon  reflexes,  ankle  clonus,  and 
the  Babinski  reflex. 

Whenever  there  occurs  a  lesion  of  the  motor  system,  whether  this  be 
in  the  cortical  centres  or  in  the  motor  tracts  anywhere  in  their  course, 
either  in  the  brain  or  spinal  cord,  there  will  always  be,  beside  the  weak- 
ness consequent  upon  such  a  lesion,  a  spastic  condition,  or  spasticity, 
increase  in  the  tendon  reflexes,  and  the  Babinski  reflex. 

Hemiplegia  may  come  on  as  result  of  lesions  at  birth,  in  the  infantile 
period,  or  that  period  in  which  the  child  cannot  walk,  in  the  time  of 
mature  development,  or  that  period  between  the  time  when  the  child  is 
fully  able  to  walk  to  early  adult  life,  about  the  twenty-first  year,  and  from 
this  time  on.  These  subdivisions  have  been  made  because  the  clinical 
type  of  the  paralysis  will  difl^er  according  to  the  time  of  life  it  comes  on. 

Hemi'plegia  Resulting  from  Injuries  at  Birth. — This  occurs  only 
when,  as  a  result  of  difficult  instrumental  labor,  there  is  an  injury  to  the 
motor  cortex  either  of  one  or  both  sides.  Pathologically  meningeal 
hemorrhages  are  most  frequently  found.  If  the  injury  is  one-sided,  a 
hemiplegia  will  result  and  the  child  from  its  earliest  life  will  be  unable 
to  use  the  limbs  of  one  side.  The  characteristic  of  this  palsy  is  that  the 
paralyzed  limbs  will  never  fully  develop  and  will  always  be  smaller  than 
those  on  the  healthy  side,  and  there  will  be  present  athetoid  movements. 
If  the  meningeal  hemorrhage  is  removed  early,  it  is  possible  to  obtain 
considerable  return  of  power. 

Should  there  be  bilateral  meningeal  hemorrhage  there  will  result  a 
paralysis  on  both  sides  of  the  body,  or  a  so-called  infantile  diplegia. 

In  such  case  there  will  be  bilateral  spasticity,  increased  reflexes,  and 
the  Babinski  reflex.  Besides,  the  limb  will  never  become  fully  developed 
and  there  wfll  be  present  athetoid  movements  of  the  upper  and  lower 
limbs  and  in  the  muscles  of  the  face,  head,  and  neck.  In  most  instances 
also  there  will  be  inability  to  talk. 

Paralysis  Coming  on  during  the  First  Two  Years  of  Life,  or  in  the  In- 
fantile Period. — ^To  understand  this  it  is  necessary  to  consider  the  devel- 
opment of  the  motor  system.  The  child,  when  it  is  born,  cannot  walk 
because  of  the  lack  of  development  of  the  motor  fibers.  This  can  be 
readily  seen  when  a  cross-section  is  made  of  the  spinal  cord  of  a  newly 
born  child,  for  the  myelin  sheaths  will  not  stain.  On  the  contrary,  if 
the  spinal  cord  of  a  chicken,  which  walks  immediately  after  birth,  be 
stained,  it  will  be  found  that  the  myelin  sheaths  are  fully  developed. 
That  is  why  the  chicken  can  walk  and  the  child  cannot.  Ordinarily  it 
takes  from  one  to  two  years  for  the  myelin  sheaths  to  obtain  full  devel- 
opment, and,  when  this  is  reached,  the  child  wfll  be  able  to  walk.  It  can 
be  readily  seen  from  this  why  it  is  an  error  to  force  or  urge  children  to 
walk  before  they  are  able  to  do  so  themselves,  and  it  also  is  an  evidence 
of  the  cause  of  the  deformities  of  such  children.  Should,  therefore,  there 
occur  a  destruction  of  the  motor  centres  because  of  an  injury,  there  will 
result  a  hemiplegia,  and,  as  is  the  case  in  paralysis  which  occurs  as  a 
result  of  meningeal  lesions,  there  will  be  besides  spasticity,  increased 


160  DISEASES  OF  THE  NERVOUS  SYSTEM 

reflexes,  the  Babinski  reflex,  lack  of  development  of  the  limbs ;  but  this 
will  not  be  so  great  as  in  lesions  at  birth.  It  can  also  readily  be  seen 
why  a  lesion  occurring  in  early  infancy  will  cause  a  greater  lack  of 
development.^  Athetoid  movements,  as  a  rule,  do  not  occur,  and  if  the 
lesion  should  be  bilateral  it  is  probable  that  there  will  not  be  much 
impairment  of  speech.  The  usual  causes  of  paralysis  at  this  age  are 
either  injuries  or,  what  is  most  common,  areas  of  inflammation,  or 
encephalitis,  resulting  from  or  complicating  such  infectious  diseases  as 
scarlet  fever,  measles,  and  diphtheria. 

Paralyses  which  Occur  between  the  Second  Year,  or  the  Infantile  Period, 
and  Full  Maturity. — A  child  grows  and  does  not  reach  full  develop- 
ment until  about  the  twenty-first  year,  sometimes  later.  The  hemi- 
plegia which  occurs  in  this  period  will  differ  from  the  paralysis  occurring 
later  only  in  the  fact  that  there  will  be  a  lack  of  development  of  the  limb, 
this  being  greater  in  the  early  periods  of  life.  The  causes  are  generally 
injury  to  the  head,  early  syphilis  of  the  nervous  system,  embolism,  or  a 
uremic  condition. 

The  hemiplegias  which  occur  after  the  twentieth  year  do  not  differ  as  to 
type,  but  they  do  as  regards  their  etiology.  It  is  a  safe  rule  to  assume 
that  when  hemiplegia  occurs  in  early  adult  life,  before  the  forty-fifth  year, 
the  cause  is  syphilis.  The  other  causes  may  be  embolism,  uremic  con- 
ditions, brain  tumors,  or  injury  to  the  head.  If  the  cause  is  syphilis, 
there  may  or  may  not  be  present  other  indications  or  early  history  of 
such  disease. 

Hemiplegias  coming  on  after  the  fortieth  year  are  usually  the  result 
of  apoplexy.     The  other  causes  are  also  operable. 

Apoplexy. — By  apoplexy  is  meant  the  bursting  of  a  bloodvessel,  the 
usual  seat  of  hemorrhage  being  in  the  lenticulostriate  artery.  A  hemor- 
rhage in  this  portion  will  usually  injure  the  posterior  limb  of  the  internal 
capsule,  thereby  giving  hemiplegia  on  the  opposite  side;  and  if  the  sensory 
and  visual  fibers  are  also  involved,  hemianesthesia  and  hemianopsia 
(Fig.  51).  Hemorrhages  in  the  other  portions  of  the  brain  and  brain 
stem  will  give  various  symptoms  according  to  their  localization.  (See 
chapter  on  Cerebral  Localization.) 

When  apoplexy  occurs,  there  is  usually  an  accompanying  shock,  the 
patient  being  rendered  unconscious.  It  is  somewhat  difficult  to  tell 
which  side  is  paralyzed,  because  in  the  period  directly  after  the  attack 
there  is  so  much  shock  that  there  is  complete  loss  of  tone  in  all  of  the 
limbs,  and  it  will  be  impossible  to  recognize  by  the  resistance  which 
is  paralyzed.  Later  on,  of  course,  tonicity  will  become  apparent  in  the 
sound  side.  It  will  be  found,  however,  that  on  the  side  of  the  paralysis 
there  will  be  drooping  of  the  lower  part  of  the  mouth,  dribbling  of  saliva, 
and  stertorous  respiration.  The  paralytic  will  bring  to  aid  all  of  the 
accessory  muscles  of  respiration  and  in  expiration  the  cheek  on  the  para- 
lyzed side  will  be  puffed  out,  and  because  of  this  there  will  be  dribbling 
of  saliva  from  the  paralyzed  to  the  healthy  side.  This  is  an  important 
sign.  Again,  if  the  patient  is  stuck  with  a  pin,  there  will  be  reflex  move- 
ment on  the  sound  side,  but  not  on  the  paralyzed  side. 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES 


161 


As  a  rule,  the  patient  will  regain  consciousness  within  a  few  hours, 
and  from  then  on  there  will  be  a  progressive  return  of  power,  as  indicated 
previously.  If,  however,  the  patient  does  not  regain  consciousness  within 
twelve  hours,  the  prognosis  is  almost  invariably  fatal. 

Wlien  hemiplegia  is  due  to  embolism,  there  is  always  an  accompanying 
heart  disease  and  the  signs  of  a  valvular  lesion.  The  onset  is  generally 
abrupt,  and  unconsciousness  is  nearly  always  present.  It  may  come  on 
at  any  age,  but  generally  in  the  young. 


Fig.  51 


Hemorrhage  into  posterior  limb  of  internal  capsule  and  optic  thalamus  causing  hemiplegia, 
hemianesthesia,  and  hemianopsia  on  the  opposite  side. 


Hemiplegia  due  to  thrombosis  nearly  always  has  a  slow  onset  and  occurs 
after  the  fortieth  year.     There  is  hardly  ever  unconsciousness. 

When  hemiplegia  is  the  result  of  syphilis,  the  onset  is  usually  abrupt 
and,  as  a  rule,  there  is  unconsciousness.  It  generally  occurs  in  persons 
before  the  fortieth  year. 

In  the  course  of  a  uremic  condition  it  is  possible  to  have  paralysis  of 

one  side  of  the  body.     It  is  characteristic,  however,  of  this  disease 

that  the  paralysis  is  never  complete,  that  it  does  not  last,  and  that  it  is 

always  accompanied  by  convulsions,  which  may  be  either  Jacksonian 

11 


162  DISEASES  OF  THE  NERVOUS  SYSTEM 

or  general  in  type.  There  are  also  present  the  accompanying  symptoms 
of  uremia,  such  as  unconsciousness,  urinous  odor,  dropsical  condition  of 
the  limbs,  and  albumin  and  casts  in  the  urine. 

The  paralyses  which  come  on  in  the  course  of  an  injury  to  the  head 
are  usually  accompanied  by  the  surgical  symptoms  of  the  injury.  This 
subject  will  be  discussed  separately,  as  will  also  paralyses  resulting  from 
brain  tumor.  In  the  latter  condition  the  hemiplegia  comes  on  very 
gradually,  and  there  are  always  the  accompanying  symptoms  of  an 
irritative  lesion  of  the  brain. 

Disturbances  in  Sensation. — ^Disturbances  in  sensation  occurring  in  the 
course  of  brain  disease  are  always  indicative  either  of  a  lesion  in  the 
sensory  cortical  centres  or  in  their  related  fibers.  The  various  forms 
of  sensation  are :  touch,  pain,  temperature  sensation,  this  including  heat 
and  cold,  bone  sensation,  and  the  senses  of  localization,  of  movement,  of 
position,  of  pressure,  the  last  four  composing  what  is  known  as  muscle 
sense.  The  ability  to  recognize  objects  placed  in  the  hand  is  known 
as  stereognosis,  while  the  inability  to  recognize  objects  is  called  astereog- 
nosis.     Their  cortical  localization  has  been  discussed. 

Disturbances  in  touch  occur  as  a  result  of  lesions  in  the  cortical  sensory 
centres  or  in  the  postcentral  and  parietal  convolutions.  It  is  character- 
istic of  the  anesthesias  the  result  of  such  lesions  that  they  are  never  com- 
plete and  may  be  segmental  in  their  distribution,  as,  for  instance,  a  patient 
may  be  able  to  recognize  touch  over  the  radial  side  of  the  hand  and  not 
over  the  ulnar.  A  complete  disturbance  of  sensation  is  nearly  always 
indicative  of  a  lesion  in  the  fibers  away  from  the  cortex,  generally  in  the 
posterior  portion  of  the  posterior  limb  of  the  internal  capsule.  Such  a 
lesion  will  produce  complete  hemianesthesia,  not  only  for  touch,  but  also 
for  pain  and  temperature. 

Disturbances  of  pain  or  of  heat  and  cold  sensation  do  not  occur  indi- 
vidually as  the  result  of  cortical  lesions,  for,  as  a  rule,  when  they  are 
present  they  are  always  associated  with  disturbances  of  touch.  Disturb- 
ance of  touch  sensation  is  the  only  form  then  which  can  occur  alone  as 
the  result  of  cortical  lesions.  Sometimes,  however,  if  there  is  an  irrita- 
tive lesion  of  the  sensory  cortical  centres,  there  may  be  attacks  of  numb- 
ness or  of  pain  in  the  corresponding  or  associated  limbs  on  the  other  side 
of  the  body.  These  spasms  of  pain  can  be  compared  to  the  Jacksonian 
convulsions  which  are  the  result  of  irritation  of  the  motor  centres. 

Alterations  in  the  senses  of  localization,  of  movement,  of  position,  and 
of  pressure  do  not  occur  individually,  and  if  there  is  disturbance  in  one 
there  are  disturbances  in  all.  Should  such  be  the  case,  the  patient  will 
be  unable  to  recognize  where  he  is  being  touched  (sense  of  localization), 
whether  a  limb  or  a  part  of  a  limb  has  been  moved  (sense  of  movement), 
the  position  in  which  the  limb  has  been  placed  (sense  of  position),  and 
whether  any  pressure  is  exerted  when  objects  are  placed  in  his  hand  (sense 
of  pressure).  All  these  make  up  muscle  sense.  If  these  alterations  are 
present,  the  patient  cannot  recognize  any  object  placed  in  his  hand,  that  is, 
he  has  astereognosis.  Combined  with  this  there  must  be  incoordination 
of  the  limbs  or  limb,  depending  upon  the  site  of  the  lesion.    Disturbances, 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES  163 

then,  of  these  functions  are  always  indicative  of  a  lesion  in  the  parietal 
lobules,  in  the  superior  if  the  lower  limbs  are  involved,  and  the  inferior 
if  the  upper.  Disturbance  in  touch  nearly  always  accompanies  the 
above  symptoms  unless  the  lesion  is  limited  to  the  parietal  convolutions 
and  to  the  cortex,  a  rather  rare  occurrence. 

The  incoordination  which  is  'present  as  a  result  of  cerebral  lesions 
differs  from  that  which  is  due  to  cerebellar  or  posterior  column  spinal 
disease  in  the  fact  that  it  is  always  unilateral  and  limited  to  the  limbs, 
depending  upon  whether  the  superior  or  inferior  or  both  parietal  lobules 
are  involved;  whereas,  in  cerebellar  ataxia  there  is  incoordination  in  all 
the  motor  functions,  and  in  spinal-cord  lesions  the  ataxia  is  bilateral 
and  limited  to  the  limbs. 

Disturbances  in  Vision. — Disturbances  in  vision  as  a  result  of  cerebral 
lesions  may  consist  either  of  a  diminution  or  loss  of  vision  and  of  such 
alterations  as  are  the  result  of  paralysis  of  one  or  more  of  the  ocular 
muscles.  Under  the  head  of  cortical  localization  have  been  discussed 
the  visual  centres  and  the  results  of  lesions  either  in  this  part  or  in  the 
primary  visual  centres,  optic  tracts,  chiasm,  and  nerves.  Under  the  head 
of  cranial  nerves  the  ocular  palsies  have  also  been  considered. 

Disturbances  in  the  Special  Senses. — Disturbances  in  the  special  senses, 
such  as  hearing,  smell,  and  taste,  occasionally  occur  as  a  result  of  destruc- 
tion of  their  cortical  centres,  but  this  is  an  extremely  rare  occurrence. 
They  are  mostly  due  to  the  involvement  of  their  respective  cranial  nerves. 

Alterations  in  Mentality. — Alteration  in  mentality  may  result  either 
from  lack  of  development,  such  as  occurs  in  idiocy  and  imbecility;  it 
may  come  on  for  no  apparent  reason,  as  is  the  case  in  different  forms  of 
insanity;  or  it  may  be  the  result  of  definite  lesions,  such  as  brain  tumors, 
abscesses,  and  injuries  to  the  head. 

In  idiocy  and  imbecility  there  is  lack  of  development  of  the  whole 
cerebrospinal  system.  The  brains  of  such  individuals  are  usually  smaller, 
there  is  not  the  usual  conformation,  and  the  convolutions  and  fissures 
are  not  well  developed.  The  prognosis  is  never  good,  and  the  only  hope 
is  that  offered  by  education. 

The  different  forms  of  insanity  will  not  be  considered  here.  It  will 
only  be  necessary  to  say  that  in  the  course  of  some  insanities  patients 
develop  delusions  that  they  have  certain  diseases  for  which  operations 
may  be  considered.  Such  operations  are  absolutely  unjustifiable,  and  will 
have  no  beneficial  effect  upon  the  delusions  and  will  only  multiply  them. 

Lesions  in  any  portion  of  the  brain  will  necessarily  influence  men- 
tality, this  depending  upon  the  location  and  extent  of  the  lesion.  Inju- 
ries to  the  brain  will  also  cause  disturbances  in  mentality,  this  depending 
upon  the  extent  of  the  injury. 

The  question  often  arises  whether  it  is  possible  to  have  insanity 
resulting  from  injury  to  the  brain.  Opinions  differ  regarding  this,  but 
it  is  probable  that  this  is  not  possible. 

Brain  Tumors. — Under  this  head  will  be  considered  tumors,  abscesses, 
areas  of  softening,  or  whatever  else  may  give  the  symptoms  of  a  neoplasm 
in  the  brain.     The  most  common  form  of  tumor  is  the  sarcoma,  next  in 


164  DISEASES  OF  THE  NERVOUS  SYSTEM 

order  being  glioma,  endothelioma,  fibroma,  fibrosarcoma,  carcinoma, 
tuberculoma,  syphiloma,  adenoma,  etc. 

Sarcoma. — ^This  form  of  brain  tumor  is  probably  more  common  than 
glioma.  The  growth  may  be  small,  flat,  or  nodular,  or  may  be  of  large 
size.  It  is  primary  and  usually  solitary.  Sarcoma  always  grows  from 
the  meninges,  periosteum,  or  cranial  bones,  or  from  the  pial  covering 
of  the  bloodvessels.  It  never  grows  from  the  brain  substance,  and 
therefore,  unlike  the  glioma,  it  always  compresses  the  brain  tissue  and 
may  be  distinct  from  it,  although  not  infrequently  it  infiltrates  the  latter. 
Even  when  growing  within  the  brain  a  distinct  margin  may  be  sometimes 
found,  due  to  the  softened  area  surrounding  it.  It  is  usually  harder  in 
consistency  than  the  glioma,  slower  in  growth,  and  very  vascular.  ■ 

The  tumor  may  soften  or  caseate,  and  myxomatous,  hemorrhagic,  and 
cystic  changes  are  not  uncommon.  Cystic  changes  are  especially  com- 
mon in  the  cerebellum,  not  only  in  sarcomata  but  also  in  gliomata.  If 
the  fibrous  tissue  is  very  marked  we  have  a  fibrosarcoma. 

Sarcoma  may  manifest  itself  as  a  diffuse  multiple  sarcomatosis.  This 
may  involve,  first,  the  nervous  substance  and  the  meninges,  and  secondly, 
the  membranes  only,  when  it  may  appear  in  the  form  of  small  tumors 
or  as  a  difi^use  infiltration.  When  the  brain  or  its  meninges  are  impli- 
cated in  sarcomatosis,  in  about  two-thirds  of  the  cases  a  tumor  of  the 
cerebellum  is  found.  Tumors  may  also  be  found  in  the  fourth  and 
lateral  ventricles,  Gasserian  ganglia,  and  pituitary  body,  in  fact  almost 
anywhere. 

It  is  important  to  remember  that  when  sarcomatosis  is  present  the 
soft  tumor  masses  grow  in  the  pia  about  the  cranial  nerves  and  spinal 
roots  and  may  produce  little  or  no  compression  or  destruction  of  the 
nervous  tissue.  It  is  because  of  this  that  few  clinical  symptoms  may 
appear,  although  there  may  be  extensive  alterations  in  the  nervous  tissue. 
A  correct  diagnosis  of  sarcomatosis  of  the  brain  and  the  pial  covering  is 
often  impossible. 

Isolated  sarcomata  are,  next  to  fibromata,  among  the  most  favorable 
forms  of  tumor  for  surgical  removal.  Of  course,  the  question  of  multiple 
sarcomatosis  must  always  be  carefully  considered  when  deciding  upon 
operation.  With  regard  to  surgical  procedure,  the  hard,  non-infiltrating 
sarcomata  are  the  most  favorable.  Experience  shows,  however,  that  a 
sarcoma  which  appears  to  be  infiltrating  when  the  brain  tumor  masses 
are  first  exposed  is  often  se{)arable  from  the  brain  substance. 

Endothelioma. — This  is  a  form  of  sarcoma  which  grows  either  from  the 
endothelial  lining  of  the  dura  or  from  the  perivascular  spaces.  It  differs 
only  from  sarcoma  in  that  the  cells  are  arranged  in  clumps  or  columns 
and  that  it  is  more  vascular.  It  never  infiltrates  the  brain  tissue,  but 
compresses  it  and  is  a  very  favorable  growth  for  removal.  Wlien  it  is 
present  there  may  be  an  accompanying  overgrowth  of  the  cranial  bones 
covering  it. 

Osteosarcoma. — Occasionally  a  sarcoma  will  grow  from  the  cranial 
bones,  or  it  may  involve  the  cranial  bones  secondarily.  In  such  cases  the 
tumor  is  called  an  osteosarcoma. 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES  1G5 

Glioma. — ^This  form  of  tumor  is  almost  always  primary  and  single, 
although  metastasis  may  rarely  occur.  The  tumor  may  be  as  small  as 
a  cherry  or  as  large  as  a  hen's  egg.  It  always  grows  from  the  brain 
substance  itself  and  is  of  slow  growth.  It  is  not  sharply  defined,  but 
infiltrates  the  brain  substance,  and  is  difficult  to  distinguish  from  normal 
brain  tissue,  although  sometimes  there  is  an  increased  consistence  and 
there  may  be  a  slight  swelling.  The  border  zone  of  the  tumor  may 
present  an  increased  number  of  bloodvessels,  and  there  may  be  islets 
of  new  tissue. 

Gliomata  may  be  hard  or  soft,  depending  upon  the  excess  of  cells  or 
fibrils,  and  have  a  yellowish  wliite  or  reddish  appearance.  Cystic  forma- 
tion is  very  common  and  it  is  possible  that  the  whole  mass  may  disappear, 
leaving  nothing  but  a  cyst  wall,  and  it  is  necessary  to  examine  micro- 
scopically the  capsule  to  determine  the  gliomatous  origin.  Cysts  form 
in  the  neighborhood  of  these  tumors,  and  a  surgeon  may  tap  one  of  these 
cyst  formations,  believing  it  to  be  the  only  lesion  present.  It  is  always 
a  wise  procedure  to  remove  a  part  of  the  cystic  wall  for  microscopic 
examination.  The  fluid  inside  of  these  cysts  may  be  whitish  or  bloody 
in  character.  Fatty,  hemorrhagic,  and  myxomatous  changes  occur  in 
gliomatous  tumors. 

Microscopically  it  is  difficult  to  distinguish  a  glioma  from  sarcoma 
unless  a  differential  stain  has  been  employed.  There  is  some  doubt  as 
to  the  simultaneous  occurrence  of  glioma  and  sarcoma,  the  so-called  glio- 
sarcoma,  as  the  former  is  of  ectodermal  and  the  latter  of  mesodermal 
origin.  A  gliosarcoma  should  be  diagnosticated  only  when  a  sarcomatous, 
perivascular,  cellular  mass  is  found  within  the  glioma.  It  can  be  readily 
understood  from  the  slow  growth  and  from  its  infiltrating  character 
why  clinical  symptoms  of  brain  tumor  do  not  always  appear  or  not  until 
late  in  the  disease.  Surgically,  it  is  difficult  or  even  impossible  to  remove 
completely  such  a  tumor. 

Glioma,  sarcoma,  and  cysts  of  various  kinds  are  more  frequent  in  the 
adult,  and  tuberculous  growths  are  more  common  in  persons  below  the 
age  of  twenty  years. 

Tuberculoma. — ^Tuberculous  growths  occurring  in  childhood  are  more 
frequently  located  in  the  cerebellum  than  in  any  other  portion  of  the  brain. 
In  the  adult  they  are  found  with  equal  frequency  in  this  region,  and  in 
the  pons  and  cerebral  cortex.  They  are  nearly  always  multiple  and 
secondary  to  a  tuberculous  process  elsewhere  in  the  body.  A  tendency 
to  symmetrical  arrangement  is  also  sometimes  observed.  Their  size 
varies  from  that  of  a  small  nodule  to  that  of  a  large  fist.  Macroscopically 
it  is  hard  to  distinguish  a  tuberculoma  from  a  syphiloma.  Both  have 
poor  bio  3d  supply  and  a  tendency  to  caseate;  the  tuberculous  growth  tends 
to  pus  formation.  Again,  both  have  a  tendency  to  grow  from  the  meninges, 
although  the  tuberculous  growths  are  found  in  the  substance  of  the 
brain  and  may  have  granulation  areas  and  miliary  tubercles  about  their 
border. 

The  growth  of  a  tubercle  may  be  either  rapid  or  slow.  Tuberculous 
tumors  may  give  no  clinical  symptoms.     This  has  been  explained  by  the 


166 


DISEASES  OF  THE  NERVOUS  SYSTEM 


slowness  of  the  growth,  the  brain  tissue  gradually  accommodating  itself 
to  increased  pressure.  It  is  possible,  however,  to  demonstrate  by  certain 
silver  stains  the  persistence  of  the  axis  cylinders  in  these  growths,  thus 
explaining  the  persistence  of  function.  Surgically,  it  is  not  advisable  to 
operate  upon  tuberculous  tumors,  as  they  are  multiple  and  cannot  all  be 
removed.  A  tuberculous  growth  may  be  part  of  a  general  tuberculous 
meningitis  or  there  may  exist  tuberculous  meningitis  alone.  If  the  symp- 
toms of  meningitis  arise,  it  is  always  a  wise  procedure  to  look  for  a  tuber- 
culous process  in  the  lungs  as  an  aid  to  diagnosis. 

Syphilitic  Growths.— Gummata  are  rarely  found  postmortem,  although 
they  are  usually  thought  to  be  the  most  common  form  of  brain  tumor 
(Fig.  52).  The  usual  results  of  syphilis  in  the  nervous  system  are 
endarteritis,  round-cell  infiltration,  and  meningitis.  The  endarteritis  is 
usually  general,  and,  because  of  the  weakening  of  the  bloodvessel  walls, 
early  hemorrhages  may  result. 

Fig.  52 


Gumma  of  the  motor  cortex  and  m.eninges,  showing  extensive  round-cell  infiltration  throughout 
the  whole  section.  Area  (a)  shows  a  gap  in  the  tissue  made  at  postmortem  because  of  adhesion 
of  brain  and  meninges  to  cranial  bones.  Clinically  there  were  Jacksonian  convulsions  limited 
to  the  upper  limb,  followed  later  by  paralysis. 

Syphilitic  meningitis  usually  involves  the  basal  membranes,  but  may 
also  involve  those  of  the  cortex.  In  the  latter  instance  the  meninges 
may  be  a  half-inch  in  thickness  and  thereby  compress  the  brain  and  give 
focal  symptoms  of  tumor.  Occasionally  the  syphilitic  process  involves 
the  brain  substance  itself,  causing  a  diffuse  cellular  infiltration,  or  the 
bones  may  be  involved,  causing  a  carious  condition  of  a  part  or  many  of 
the  cranial  bones. 

When  basal  meningitis  occurs  it  may  involve  the  whole  extent,  or, 
what  is  more  often  the  case,  only  the  meninges  near  the  chiasm,  thus 
involving  the  second,  third,  fourth,  and  sixth  cranial  nerves. 

At  times,  instead  of  meningitis  there  may  be  diffuse  areas  of  softening 
throughout  the  brain,  these  areas  being  yellowish  red  in  color,  soft  in 
consistency,  and  well  defined  from  the  surrounding  brain  tissue. 


y 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES  167 

Syphilitic  growths  are  usually  rapid  in  development,  but  it  must  be 
remembered  that  the  various  pathological  conditions  which  lead  on  to 
the  growths  have  long  been  present. 

Fibromata. — ^These  tumors  are  rare,  but  they  are  relatively  more  fre- 
quent in  the  cerebellum  than  in  the  cerebrum,  and  especially  in  the 
cerebellopontile  angle. 

A  fibroma  invading  the  cerebellopontile  angle,  or  the  angle  between 
the  pons  and  the  cerebellum,  may  be  only  part  of  a  general  neurofibro- 
matosis. This,  however,  is  rare,  and  usually  a  tumor  in  this  area  is  the 
only  expression  of  this  process.  The  growth  is  slow  and  generally 
unilateral,  although  in  rare  instances  it  may  be  present  on  both  sides. 
Experience  has  shown  that  it  is  more  common  on  the  left  side  in  the 
ratio  of  three  to  two. 

The  fibroma  may  be  as  small  as  a  cherry  or  the  size  of  a  large  egg. 
The  growth  is  firm,  hard,  nodular,  and  has  a  distinct  capsule  surround- 
ing it.  When  located  in  the  cerebellopontile  angle  it  is  generally  loosely 
attached  to  the  brain  by  an  atrophic  nerve  trunk  and  a  few  blood- 
vessels or  a  meningeal  process.  These  attachments  may  be  easily  rup- 
tured. These  tumors  are  in  organic  relations,  especially  with  the  acoustic 
nerve,  and  more  rarely  with  the  trigeminus  and  facial  nerves.  They 
nearly  always  grow  from  the  endoneurium  and  rarely  from  the  perineu- 
rium or  epineurium.  Consequently  it  is  possible  to  find  medullated  nerve 
fibers  either  in  the  periphery  of  the  tumor  or  in  its  centre.  As  a  rule,  if 
many  cranial  nerves  are  involved,  there  is  a  general  neurofibromatosis. 

The  fibroma  may  undergo  a  cystic,  fatty,  or  myxomatous  degeneration. 
Very  often  in  the  advanced  stages  it  may  assume  a  sarcomatous  tendency. 
Histologically  there  is  present  connective-tissue  structure,  with  entire 
absence  of  nerve  elements  except  sometimes  a  few  medullated  nerve 
fibers  either  in  the  periphery  or  its  central  part.  These  are  remnants 
of  the  nerve  on  which  the  fibroma  grows,  and  should  not  be  mistaken  for 
a  part  of  the  newgrowth. 

Sometimes  in  association  with  fibroma  of  the  cerebellopontile  angle 
there  may  be  cortical  changes  consisting  in  hyperplasia  and  hypertrophy 
of  the  glia  cells  of  the  cortex,  or  there  may  be  present  an  endothelioma  or 
psammoma  of  the  dura  mater.  At  times  the  fibromatous  process  may 
involve  the  whole  intracranial  portion  of  the  acoustic  or  other  nerves. 

These  tumors  compress  greatly  the  lateral  lobes  of  the  cerebellum,  the 
pons,  and  the  medulla  oblongata.  At  times  even  the  temporal  lobe  may 
be  compressed.  Because  of  the  slow  growth  and  nature  of  the  tumor 
clinical  symptoms  may  not  appear  at  all  or  only  late  in  the  disease. 
Tumors  of  the  cerebellopontile  angle  are  among  the  most  favorable 
for  surgical  removal. 

Carcinoma. — Carcinoma  of  the  brain  is  always  secondary  to  growths 
elsewhere  in  the  body,  generally  in  the  stomach,  lungs,  or  breast. 
The  tumor  may  grow  in  the  substance  of  the  brain,  but  mostly  it  grows 
from  the  dura  or  the  cranial  bones.  It  may  be  as  small  as  a  millet 
seed  or  may  be  of  large  size,  and  may  occur  anywhere  in  the  brain 
substance.     At  times  there  may  be  an  infiltration  of  cancer  cells  in  the 


168 


DISEASES  OF  THE  NERVOUS  SYSTEM 


pia,  covering  the  whole  brain  substance.  This,  however,  is  a  rare 
occurrence.  The  possibihty  of  toxic  changes  must  be  considered,  as  it  is 
not  improbable  that  through  intoxication  caused  by  carcinoma  elsewhere 
in  the  body,  symptoms  of  tumor  may  be  present. 

Such  other  tumors  as  osteoma  (Fig.  53),  adenoma,  cholesteatoma,  lipoma, 
and  psammoma  very  rarely  occur  in  the  brain,  and,  as  they  do  not  differ 
from  similar  growths  elsewhere,  will  not  be  considered. 

Cysts. — Cystic   degeneration   of 
^^^"  53  gliomata   and   sarcomata  is  very 

common  and  has  already  been  dis- 
cussed. Other  tumors,  as  fibroma 
and  carcinoma,  are  prone  to  un- 
dergo cystic  change,  but  more 
rarely.  It  is  possible  for  the 
whole  tumor  to  disappear  and 
only  the  cyst  remain,  so  that 
microscopic  examination  will  be 
necessary  to  detect  the  small 
tumor  mass  in  the  walls  of  the 
cyst. 

Congenital  cysts  may  occur  in 
the  fourth  and  lateral  ventricles 
or  in  the  substance  of  the  brain. 
This,  however,  is  a  rare  occur- 
rence. 

The  most  common  cystic  changes 
found  in  the  brain  are  due  to  para- 
sitic growth,  the  cysticercus  cellu- 
losacB  and  the  echinococcus.   These, 
however,  are  so  rare  in  this  country  that  they  will  not  be  considered. 

Cysts  due  to  traumatism  may  occur,  but  their  genesis  is  by  no  means 
clear.  It  is  probable,  however,  that  they  are  the  result  of  a  hemorrhage 
which  has  occurred  at  birth  or  soon  after.  As  the  brain  tissue  at  this 
time  of  life  is  not  fully  developed,  cystic  changes  or  porencephalus  may 
result. 

Cystic  tumors  occasionally  grow  from  the  choroid  plexus  in  any  of 
the  ventricles.  These  may  not  give  any  symptoms,  but,  if  sufficiently 
large,  will  compress  the  ventricular  walls  and  the  surrounding  brain  tissue. 
The  Influence  of  Brain  Tumors  upon  the  Surrounding  Struxitures. — At 
operation  when  the  dura  is  removed  there  is  nearly  always  increased 
tension  and  the  parts  may  bulge.  The  surface  of  the  brain  is  flat  and 
the  fissures  may  be  abolished,  and  the  pia  covering  the  neoplasm  is 
generally  poor  in  blood  supply.  The  tissues  near  the  growth  may  be 
softened.  Pressure  symptoms  nearly  always  result,  this  depending 
upon  the  nature  of  the  tumor,  the  extent  of  its  growth,  and  its  location. 
The  greatest  pressure  is  nearly  always  exerted  upon  the  nearby  structures, 
but  often  a  tumor  of  the  cortex  may  exert  pressure  upon  the  cranial 
nerves  at  the  base  of  the  brain. 


Osteoma  of   right  frontoparietal  bones,    caus- 
ing pressure  upon  the  brain  with  left  hemiplegia. 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES  IG9 

The  cerebrospinal  fluid  may  be  increased  in  brain  tumor,  but  this  is 
especially  so  when  the  growth  is  in  the  posterior  cranial  fossa,  because 
pressure  here  is  exerted  directly  upon  the  communication  between  the 
lateral  and  fourth  ventricles  or  upon  the  veins  of  Galen,  which  convey 
the  blood  from  the  choroid  plexus  to  the  sinus  rectus.  Because  of  this, 
increased  tension  results  in  the  lateral  and  third  ventricles,  the  latter 
causing  direct  pressure  upon  the  optic  nerves. 

Internal  Hydrocephalus. — This  condition  is  most  often  caused  by  brain 
tumor,  but  in  children  it  is  either  congenital  or  the  result  of  some  early 
pathological  condition.  The  cerebrospinal  fluid  is  probably  secreted 
by  the  choroid  plexus,  and,  if  there  is  any  interference  with  the  normal 
outflow  of  the  fluid,  or,  if  there  is  an  overproduction,  there  will  neces- 
sarily result  a  dilatation  of  the  ventricles,  or  internal  hydrocephalus. 
The  causes  may  be  congenital,  such  as  closure  of  the  foramen  of 
Magendie  or  of  the  aqueduct  of  Sylvius  or  an  aberrant  secretion  of 
the  choroid  plexus.  When  this  disease  appears  later  in  life  the  closure 
of  one  of  these  foramina  may  result  from  a  basilar  meningitis,  which  is 
usually  of  a  tuberculous  nature.  Whatever  the  cause,  the  gradual  in- 
crease of  fluid  in  the  ventricles  will  increase  the  size  of  the  cranial  cavity 
and  cause  pressure  upon  the  brain  substance,  with  consequent  atrophy 
and  loss  of  function. 

If  the  causes  are  congenital  the  child  may  be  born  with  a  very  large 
head,  but  in  most  instances  it  does  not  become  apparent  until  after  birth, 
when  it  will  be  noticed  that  the  development  of  the  child  both  physically 
and  mentally  is  delayed.  The  head  gradually  becomes  large,  especially 
in  the  frontal  and  middle  portions,  the  fontanelles  bulge  and  do  not  close, 
and  the  head  sometimes  assumes  an  enormous  circumference.  The 
face  does  not  show  any  deformity,  with  the  exception  that  the  eyes  may 
bulge.  Coincident  with  this  it  will  be  noticed  that  the  limbs  do  not  be- 
come developed  and  soon  show  an  increasing  weakness,  with  rigidity 
and  exaggerated  reflexes  and  the  Babinski  phenomenon  with  contrac- 
tures. The  mentality  is  poor,  although  sometimes  there  may  be  con- 
siderable development.  Associated  with  internal  hydrocephalus  there 
may  be  a  rachitic  condition  of  the  chest. 

There  is  a  form  of  hydrocephalus  known  as  external  hydrocephalus ,  by 
which  is  meant  an  accumulation  of  fluid  in  the  cortical  meninges.  This 
occurs  nearly  always  in  association  with  chronic  meningitis  and  will  be 
discussed  under  that  head. 

Abscess  of  the  Brain. — The  localizing  symptoms  of  an  abscess  of  the 
brain  are  similar  to  those  of  any  other  lesion  or  growth.  Because  of  the 
fact  that  most  abscesses  occur  as  a  complication  of  middle  ear  disease 
or  extension  of  such  inflammation,  most  pus  cavities  or  abscesses  are 
to  be  found  either  in  the  temporal  area,  cerebellopontile  angle,  or  in 
the  cerebellum;  or,  what  often  happens,  besides  a  lesion  either  in  the 
temporal  or  cerebellar  areas  there  may  also  be  a  meningitis  with  its 
accompanying  symptoms. 

Specifically  it  cannot  be  said  that  there  are  any  general  symptoms 
which  indicate  an  abscess  in  the  brain  (p.  236).     There  may  be,  as  is 


170  DISEASES  OF  THE  NERVOUS  SYSTEM 

usually  the  case  in  any  growth,  headache,  nausea,  vomiting,  vertigo,  and 
sometimes  choked  disk,  these  depending  upon  the  extent  of  the  lesion 
and  the  pressure  exerted  in  the  cranial  cavity.  There  may  or  may  not 
be  changes  in  the  temperature,  such  as  result  from  pus  elsewhere,  and  a 
slow  pulse.  The  other  symptoms  will  depend  upon  the  location  of  the 
lesion,  whether  temporal  or  cerebellar. 


J.U?Ch5:.S<»- 


Abscess  in  pia  in  left  cerebellopontile  angle,  causing  cerebellar  incoordination  and  paralysis  of 
the  sixth,  seventh,  and  eighth  nerves  on   the   same  side.     Drawing  shows  wall  of  abscess. 

The  Diagnosis  of  Tumors  of  the  Cerebrum. — -In  the  preceding  pages  the 
individual  symptoms  of  tumors  have  been  considered  and  analyzed,  and 
continuous  reference  will  be  made  to  their  contents.  The  collective 
symptoms  as  they  occur  in  brain  tumors  will  now  be  discussed. 

The  general  symptoms  of  hrain  tumor  are  headache,  nausea,  vomiting, 
vertigo  or  dizziness,  and  choked  disk.  As  a  rule,  all  these  symptoms  are 
present  in  a  tumor  of  fairly  large  dimensions,  but  a  growth  may  exist 
without  the  presence  of  any  of  these.  Such  a  growth,  however,  must  be 
small  and  of  such  character  as  not  to  cause  pressure.  The  symptoms 
which  are  present  in  the  great  majority  of  cases  are  headache  and 
choked  disk. 

The  headache  may  be  localized  to  the  site  of  the  lesion,  but,  as  a  rule,  it 
is  general.  Choked  disk  occurs  in  about  90  per  cent,  of  cases,  and  may  be 
greater  on  the  side  of  the  tumor.  The  swelling  of  the  optic  nerves  is 
always  greater  in  cerebellar  lesions  and  comes  on  earlier  than  in  cerebral 
lesions.    > 

Nausea,  vomiting,  and  vertigo  are  especially  prone  to  be  present  when 
the  growth  is  large  and  great  intracranial  pressure  exists.  These  symp- 
toms are  also  more  liable  to  be  present  in  tumors  which  press  upon  the 
medulla,  as  is  the  case  in  occipital  lesions  and  in  tumors  of  the  cerebellum. 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES  171 

When  considering  the  symptoms  of  brain  tumors,  the  side  on  which 
such  a  growth  occurs  must  be  taken  into  consideration.  Tumors 
which  are  located  on  the  left  side  of  the  brain  can  be  more  readily 
detected  because  our  knowledge  of  localization  is  better  on  this  side. 
This,  of  course,  is  in  a  right-handed  individual.  The  contrary  would  be 
true  of  a  left-handed  person. 

It  is,  of  course,  impossible  to  tell,  when  the  symptoms  of  a  brain  tumor 
are  present,  exactly  what  the  nature  of  the  growth  may  be.  If  there  are 
present  elsewhere  in  the  body  certain  conditions,  such  as  carcinoma, 
tuberculosis,  or  abscess  of  the  lung,  or,  if  there  is  a  history  or  other  evi- 
dence of  syphilis,  the  presumption  is  justifiable  that  similar  conditions 
exist  in  the  brain,  providing  the  symptoms  come  on  in  regular  order. 
A  growth  in  the  cerebral  cortex  is  more  liable  to  be  sarcoma  or  glioma, 
while  in  the  brain-stem  glioma  and  tuberculoma  are  more  common. 

It  is  also  important  from  a  surgical  point  of  view  to  differentiate 
between  a  cortical  and  a  subcortical  growth.  A  tumor  which  is  cortical 
may  in  time  involve  the  subcortex  and  a  subcortical  tumor  may  in  time 
involve  the  cortex.  Generally  speaking,  a  cortical  lesion  will  always  give 
irritative  phenomena.  If  in  the  motor  cortex,  there  will  result  Jack- 
sonian  convulsions  on  the  opposite  side,  to  be  followed  later  by  paralysis. 
If  in  the  sensory  cortex,  there  will  first  be  numbness  and  pains  of  the 
Jacksonian  type,  this  to  be  followed  later  by  anesthesia.  If  the  location 
is  in  the  occipital  lobes,  there  will  first  be  irritative  visual  phenomena, 
such  as  scintillating  scotomata  in  the  visual  fields  related  to  these  areas, 
and  later  loss  of  vision.  Generally  speaking,  then,  in  a  cortical  growth 
there  will  be  irritative  phenomena,  to  be  followed  by  paralytic  symptoms. 

In  a  subcortical  growth  the  symptoms  will  depend  entirely  upon  what 
fibers  are  cut  off,  as,  in  the  subcortex,  a  tumor,  no  matter  how  small,  will 
always  involve  fibers  concerned  with  more  than  one  function.  The  symp- 
toms of  a  lesion  in  this  area  will  always  be  greater  in  number  than  in  a 
cortical  lesion,  for  in  the  latter  instance  a  tumor  may  involve  only  a  very 
limited  portion  of  the  cortex,  thus  giving  only  a  few  symptoms.  Again 
in  a  subcortical  lesion  irritative  symptoms  are  not  liable  to  occur,  and 
the  earliest  symptoms  are  those  of  loss  of  function  (Figs.  55  and  56). 

It  is  well  known  that  tumors  have  a  predilection  for  certain  areas. 
These  are  the  frontal,  central  or  motor,  parietal,  occipital,  and  temporal. 
The  symptoms  which  occur  in  growths  of  these  parts  will  be  taken  up  in 
order. 

Tumors  of  the  Frontal  Lobe. — Tumors  in  this  area  are  not  very  common. 
The  growths  more  often  are  of  the  sarcomatous  variety  and  in  most 
instances  grow  from  the  frontal  bones  or  from  the  orbital  plate.  When 
the  neoplasm  is  limited  to  the  frontal  lobe  itself,  there  are,  as  a  rule,  very 
few  localizing  symptoms.  In  the  frontal  lobes  have  been  placed  the 
centres  for  higher  psychic  functions,  this  being  especially  so  in  the  left, 
but  it  cannot  be  said  that  any  special  mental  symptoms  occur  from  de- 
struction of  these  areas.  The  usual  mental  symptoms  are  gradual  change 
in  disposition,  and  impairment  of  intellect,  especially  the  memory  and  the 
power  of  reasoning.     As  can  readily  be  seen,  these  symptoms  may  occur 


172 


DISEASES  OF  THE  NERVOUS  SYSTEM 
Fig.  55 


Subcortical  gliomatous  tumor  (A),  causing  disturbance  of  motion  and  sensation  on  the  opposite 
side.  The  symptoms  were  slow  in  onset,  and,  because  of  the  nature  of  the  growth,  there  were 
few  general  manifestations.     A  decompressive  operation  was  performed  by  Dr.  Martin. 


Fig.   56 


Horizontal  sections  of  cerebral  hemisphere,  showing  extent  of  gliomatous  tumor  infiltration. 
There  was  paralysis  of  the  opposite  side  of  the  body,  motor  aphasia,  headache,  dizziness,  and 
mild  choked  disk. 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES 


173 


Fig.  57 


from  tumors  in  any  portion  of  the  brain.  Headache  may  or  may  not 
be  present  and  is  prone  to  be  localized  to  the  orbit  and  frontal  bones. 
Nausea,  vomiting,  and  dizziness  are  not  very  common,  and  choked  disk 
is  a  rather  rare  occurrence  except  in  those  instances  in  which  the  tumor 
is  mostly  localized  to  the  orbital  part  of  the  frontal  lobes  and  direct 
pressure  is  exerted  upon  the  optic  nerve,  in  which  case  the  choked  disk 
is  unilateral.  In  the  latter  instance  the  olfactory  nerve  is  also  pressed 
upon,  causing  loss  of  the  sense  of 
smell  on  that  side.  If  the  tumor  is 
of  large  size  and  involves  the  pre- 
central  convolution,  motor  symp- 
toms will  be  present  (Fig.  57). 

In  the  posterior  portion  of  the 
second  frontal  convolution  have 
been  placed  the  centres  for  the 
movement  of  the  head  and  eyes, 
and,  if  a  lesion  irritates  these 
centres,  conjugate  deviation  of  the 
head  and  eyes  or  of  both  to  the  op- 
posite side  will  result.  If  the  lesion, 
however,  destroys  these  parts,  the 
head  and  the  eye  will  be  directed 
to  the  side  of  the  lesion.  This  is 
because  of  the  unrestrained  action 
of  the  muscles  which  are  inner- 
vated by  the  opposite  cortical  cen- 
tres. If  the  lesion  involves  the 
inferior  posterior  portion  of  the 
third  frontal,  or  Broca's,  convolu- 
tion, motor  aphasia  will  be  present. 

The  frontal  lobes  are  in  direct 
connection  with  the  opposite  cere- 
bellar lobe  by  the  so-called  fronto- 
cerebellar  fibers.  In  a  growth  of 
the  frontal  lobe,  in  which  the 
tumor  is  largely  subcortical,  cere- 
bellar symptoms  may  result,  and 
it  is  difficult  to  differentiate  the 
symptoms  from  those  of  cerebellar 
lesion.  This,  however,  is  a  very 
rare  occurrence. 

Another  symptom  which  is  sometimes  supposed  to  be  present  is  an 
abnormal  tendency  for  poor  jokes,  or  the  "Witzelsucht"  of  the  Germans. 
This,  however,  is  of  questionable  value. 

The  symptoms,  then,  of  a  tumor  in  the  frontal  lobe  are  headache, 
localized  mostly  to  the  frontal  bones,  occasional  nausea,  vomiting  or 
vertigo,  and  occasional  optic  neuritis,  which  is  mostly  unilateral  and 
confined  to  the  side  of  the  lesion.  The  special  symptoms  are  loss  of 
memory  and  change  in  disposition. 


Tumor  of  frontal  lobe,  causing  disturbances 
of  mentality  with  loss  of  memory  and  reasoning, 
also  some  headache  and  optic  neuritis. 


174  DISEASES  OF  THE  NERVOUS  SYSTEM 

If  the  tumor  is  of  large  size  and  presses  upon  the  adjoining  motor  areas, 
the  above  symptoms  are  accentuated,  and  there  may  be  in  addition  motor 
symptoms  which  may  be  either  of  an  irritative  or  a  paralytic  character 
and  which  are  confined  to  the  limbs  of  the  opposite  side,  conjugate 
deviation  of  the  head  or  eyes,  or  of  both,  and  motor  aphasia. 

Tumors  of  the  Motor  Area. — Growths  in  this  location  are  more  common 
than  in  any  other  portion  of  the  cerebrum  and  are  mostly  sarcomata 
or  gliomata;.  The  symptoms  will  depend  upon  the  location  and  extent 
of  the  lesion.  If  a  growth  is  limited,  for  instance,  to  the  centre  for  move- 
ment of  the  upper  limb,  the  symptoms  will  be  referred  to  this  part.  If 
the  lesion  is  of  large  extent,  the  symptoms,  of  course,  will  be  referred  to 
the  related  parts.  Jacksonian  or  focal  convulsions  nearly  always  result 
from  a  cortical  lesion.     A  tumor,  for  instance,  involving  the  centre  for 

Fig.  58 


Tumor  involving  arm  centre  in  precentral  convolution.  The  symptoms  were  those  of  Jack- 
sonian convulsions  in  one  arm  followed  by  paralysis,  accompanied  by  headache,  nausea,  vomiting, 
stupor,  and  choked  disk. 

the  upper  limb  will  give  Jacksonian  convulsions  beginning  in  this  limb. 
If  the  growth  extends  downward,  the  movement  will  extend  from  the 
upper  limb  to  the  muscles  of  the  head  and  face.  If  the  growth  extends 
from  the  middle  to  the  upper  portion  of  the  precentral  lobe,  the  con- 
vulsions will  extend  from  the  arm  to  the  lower  limb.  It  must  be  remem- 
bered that  a  convulsion  that  is  first  Jacksonian  may  become  general  in 
character,  and  that  in  an  epileptic  convulsion  there  may  sometimes  be 
Jacksonian  manifestations.  If  the  tumor  destroys  the  motor  areas, 
paralysis  in  the  related  parts  will  result. 

Lesions  in  the  motor  area  are  only  rarely  confined  to  the  precentral 
convolution  and  mostly  also  involve  the  postcentral  convolutions  or  the 
sensory  centres,  in  which  case  sensory  symptoms  will  be  present  in 
addition  to  the  motor.  If  the  lesion  is  irritative,  there  will  be  pains  of  a 
Jacksonian  type  in  the  limbs  of  the  opposite  side;  or,  if  the  lesion  is  destruc- 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES 


175 


tive,  disturbances  of  sensation  or  anesthesia  in  the  related  limbs  on  the 
opposite  side  will  result. 

If  the  tumor  involves  the  frontal  lobes,  and  especially  the  head  and 
eye  centres,  conjugate  deviation  will  result  to  the  opposite  side  if  the  lesion 
is  irritative,  and  to  the  same  side  if  the  lesion  is  destructive.  If  the  tumor 
is  on  the  left  side  of  the  brain  in  a  right-handed  individual,  motor  aphasia 
will  also  be  present  (Fig.  58). 

As  a  rule,  tumors  in  the  motor  area  give  symptoms  of  great  pressure, 
and  headache,  nausea,  vomiting,  and  choked  disk  are  present  in  most 
instances.  Some  of  these  symptoms  may,  of  course,  be  absent,  but,  as  a 
rule,  headache  and  choked  disk  are  present. 

The  symptoms  then  of  a  tumor  confined  to  the  motor  area  are  headache, 
nausea,  vomiting,  choked  disk,  and  Jacksonian  convulsions  on  the  oppo- 
site side,  to  be  followed  later  by  paralysis  depending  upon  the  extent  of 
the  lesion. 


Fig.  59 


Recurring  sarcoma    of  motor   sensory   area.     Tumor   first   removed   by   Dr.  Martin.     Symptoms 
were  those  of  hemiplegia,  incomplete  hemianesthesia,  and  sensory  aphasia. 


If  the  tumor  invades  the  postcentral  convolution,  there  are  in  addition 
sensory  symptoms,  such  as  pains  and  disturbances  in  sensation  for  touch 
and  pain.  If  the  growth  invades  the  frontal  lobes,  there  may  be  at  first 
conjugate  deviation  of  the  head  and  eyes  to  the  opposite  side  and  later 
to  the  same  side.  A  lesion  in  the  left  side  of  the  brain  in  a  right-handed 
individual  will  also  always  give  motor  aphasia.  The  contrary  is  true  in 
left-handed  persons. 

Tumors  of  the  Sensory  Area. — ^This  includes  the  postcentral  and  superior 
and  inferior  parietal  convolutions.  Growths  involving  only  this  part  are 
very  rare,  for  in  most  instances  the  adjoining  motor  centres  are  also 


176 


DISEASES  OF  THE  NERVOUS  SYSTEM 


diseased.  As  has  already  been  stated,  most  tumors  of  the  motor  area 
involve  the  postcentral  convolution  (Figs.  59  and  60). 

Isolated  tumors  involving  either  the  superior  or  the  inferior  parietal 
convolution  may  rarely  occur.  In  such  case  a  lesion  of  the  superior 
parietal  convolution  will  give  disturbance  in"  the  sense  of  localization,  of 
position,  of  movement,  of  pressure  and  ataxia  of  the  lower  limb,  with 
inability  to  recognize  objects  placed  against  the  sole  of  the  foot. 

A  lesion  involving  the  inferior  parietal  convolution  will  give  the  above 
symptoms  in  the  upper  limb  instead  of  the  lower.  In  addition,  in  both 
there  may  be  headache,  nausea,  vomiting,  and  choked  disk. 


Fig.  60 


Sarcomatous  growth   removed  postmortem. 

In  most  instances  we  have  the  adjoining  postcentral  convolution 
involved,  and  there  is  in  addition  to  the  symptoms  already  enumerated 
disturbance  in  touch  and  pain.  Very  often  in  irritative  lesions  of  the 
sensory  areas  there  may  be  numbness  and  paroxysms  of  pain  in  the 
related  limbs  similar  in  character  to  the  Jacksonian  spasms,  the  result 
of  motor  irritation. 

If  the  growth  involves  the  adjoining  occipital  convolution,  disturbance 
in  vision  will  result.  If  the  lesion  is  left-sided  in  a  right-handed  person 
and  the  angular  gyrus  is  involved,  there  is  in  addition  word  and  letter 
blindness,  this  causing  inability  to  read  or  write  voluntarily  or  from 
dictation. 

Tumors  of  the  Occipital  or  Visual  Area. — Growths  in  this  area  are  not 
very  common.  They,  as  a  rule,  cause  early  pressure  symptoms,  and 
disturbances  of  vision  are  among  the  first  manifestations.  These  may  be 
flashes  of  light  or  scintillating  scotomata  in  the  related  visual  fields,  to  be 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES 


177 


followed  later  by  disturbance  of  vision,  either  for  light  or  for  colors, 
and  lastly  loss  of  half  vision,  or  hemianopsia.  If  the  lesion  is  right-sided, 
there  will  be  left  lateral  homonymous  hemianopsia,  and  vice  versa. 
Occipital  headache  is  always  marked,  as  are  also  nausea,  vomiting,  and 
vertigo,  and  choked  disk  will  come  on  early.  This  is  because  direct 
pressure  is  exerted  upon  the  cerebellum.  There  may  be  in  addition  the 
symptoms  of  cerebellar  incoordination  (Fig.  61). 

If  the  growth  involves  the  adjoining  parietal  or  angular  gyres,  their 
related  symptoms  will  occur. 


Fig.  61 


Endothelioma  in  one  occipital  lobe  (a),  causing  the  general  symptonas  of  brain  tumor  with 
hemianopsia  of  the  opposite  side. 


Tumors  of  the  Temporal  Lobes. — Growths  in  this  area  are  of  rare  occur- 
rence, in  most  instances  the  adjoining  parietal  lobes  being  also  involved. 
If  the  lesion  is  on  the  left  side  of  the  brain  in  right-handed  individuals  and 
the  growth  is  confined  to  the  temporal  lobes,  the  symptoms  will  be  those 
of  pure  sensory  aphasia,  i.  e.,  the  patient  will  be  able  to  talk,  but  he  will 
have  loss  of  memory  for  words  as  to  their  meaning  and  his  speech  will 
be  unintelligible. 

If  the  lesion  is  on  the  right  side  of  the  brain  in  right-handed  indi- 
viduals, no  localizing  symptoms  will  be  present.  This  is  a  so-called 
"silent  area"  of  the  brain.  There  will,  of  course,  be  headache,  nausea, 
vomiting,  and  choked  disk.  If  the  growth  involves  the  adjoining  parietal 
lobes,  their  related  symptoms  will  occur, 
12 


178 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Tumors  in  the  Subcortex,  Cms,  Pons,  and  Medulla. — ^The  symptoms  of 
lesions  in  these  areas  will  not  be  discussed,  inasmuch  as  surgical  removal 
of  tumors   in   these   areas   is   impossible.     The   localizing  symptoms, 


Fig.  62 


Tumor  of  lateral  ventricle  causing  pressure  on  .internal  capsule  and  optic  thalamus,  with 
hemiplegia  and  incomplete  disturbance  of  sensation  upon  the  opposite  side,  accompanied  by 
headache,  vomiting,  vertigo,  and  choked  disk. 


Fig.  63 


Tumor  of  aqueduct  of  Sylvius  in  the  pons,  causing  blocking  up  of  flow  of  cerebrospinal  fluid 
•  and  secondary  internal  hydrocephalus.     There  were  only  general  pressure  symptoms. 

however,  have  been  discussed  under  the  head  of  cortical  localization. 
In  addition  to  the  symptoms  there  enumerated  there  will  be  the  usual 
symptoms  of  brain  tumor,  such  as  headache,  nausea,  vomiting,  vertigo, 
and  choked  disk  (Figs.  62  and  63). 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES  179 

Tumors  of  the  Cerebellum. — Growths  in  the  posterior  cranial  fossa 
may  involve  either  the  substance  of  the  cerebellum  or  the  surrounding 
structures,  the  latter  giving  the  symptoms  of  cerebellar  disease  because 
of  pressure  or  involvement  of  this  organ.  It  is  also  necessary  to  consider 
growths  which  occur  in  the  cerebrum,  but  which,  because  of  pressure, 
give  symptoms  of  cerebellar  disease. 

The  general  symptoms  of  tumors  of  the  cerebellum  are  headache, 
nausea,  vomiting,  vertigo,  choked  disk,  and  incoordination. 

Headache,  as  a  rule,  is  present,  is  more  severe  in  lesions  of  the  cere- 
bellum itself  than  in  extracerebellar  lesions,  and  is  generally  localized  to 
the  back  part  of  the  head  and  neck.  Sometimes  the  pain  is  so  severe 
as  to  cause  retraction  of  the  head.    Occasionally  no  headache  is  present. 

Nausea  and  vomiting  are,  as  a  rule,  present  early  and  are  more  intense 
in  intracerebellar  lesions. 

Vertigo  is  present  nearly  always  and  is  one  of  the  prominent  symptoms. 
It  may  consist  in  a  feeling  of  dizziness  in  which  objects  may  swim  before 
the  eyes  and  the  patient  feels  as  if  he  were  losing  consciousness,  or  in  a 
feeling  of  rotation  of  objects  before  the  eyes  or  of  rotation  of  self.  Vertigo, 
as  a  rule,  is  more  marked  in  extracerebellar  lesions  and  is  probably 
dependent  upon  involvement  of  the  vestibular  branch  of  the  eighth  nerve. 
It  is  the  opinion  of  some  that  when  there  is  a  sensation  of  rotation  of 
objects  before  the  eyes,  whether  the  lesion  be  intra-  or  extracerebellar, 
it  is  always  from  the  diseased  to  the  healthy  side.  When  there  is  a 
sensation  of  rotation  of  self,  the.  direction  is  the  same  in  intracerebellar 
lesions,  but  opposite  in  extracerebellar  lesions.  This  symptom,  however, 
is  by  no  means  certain. 

Occasionally  a  sense  of  dizziness  is  experienced  when  the  eyes  are 
deviated  to  one  side,  generally  to  the  side  of  the  lesion,  but  there  is  no 
dizziness  when  the  head  is  deviated.  In  such  case  the  vertigo  may 
be  due  to  a  weakness  of  one  of  the  ocular  muscles  and  is  not  a  true 
cerebellar  vertigo. 

Choked  disk  is  one  of  the  early  and  most  constant  symptoms  of  lesions 
in  the  posterior  cranial  fossa.  As  a  rule,  it  comes  on  earlier  and  is 
more  marked  than  in  lesions  of  the  cerebrum.  It  may  be  greater  on  the 
side  of  the  lesion.  Sometimes  choked  disk  comes  on  after  the  appear- 
ance of  other  cerebellar  symptoms,  and,  when  it  does  so,  its  development 
is  usually  very  rapid.  Tumors  of  the  substance  of  the  cerebellum  itself 
usually  give  a  greater  choked  disk  because  of  the  direct  pressure  exerted 
upon  the  fourth  ventricle. 

Incoordination  results  from  a  lesion  in  any  portion  of  the  cerebellum 
or  its  connections.  As  has  already  been  stated,  it  is  probable  that  the 
cerebellum  is  concerned  with  the  coordination  of  every  voluntary  move- 
ment, and  therefore  whatever  symptoms  are  produced  are  dependent 
upon  this. 

A  lesion  in  the  middle  portion  or  the  vermis  will  produce  the  greatest 
amount  of  incoordination,  this  being  apparent  on  either  side  of  the  body, 
whereas  lesions  involving  only  a  lateral  lobe  will  produce  a  preponder- 
ance of  symptoms  on  the  side  of  the  lesion.     Tumors  outside  of  the  cere- 


180  DISEASES  OF  THE  NERVOUS  SYSTEM 

bellum  will  produce  mostly  unilateral  symptoms  unless  the  middle  lobe 
or  the  vermis  is  involved,  in  which  case  bilateral  ataxic  symptoms  will  be 
present. 

The  incoordination  of  cerebellar  disease  is  manifested  only  when  an 
effort  is  made  and  is  not  dependent  upon  peripheral  symptoms,  i.  e., 
there  is  never  disturbance  of  sensation  and  no  involvement  of  muscular 
sense.  This  incoordination  becomes  apparent  in  the  gait,  station,  posi- 
tion of  the  head  and  limbs,  movements  of  the  eyeballs,  head,  and  limbs, 
and  in  talking,  eating,  and  swallowing.  These  will  be  taken  up  in 
order. 

When  considering  the  ataxia  present  in  cerebellar  diseases  it  is  neces- 
sary to  consider  also  the  possible  influence  of  the  weakness  and  the  atonia 
which  sometimes  results  from  lesions  of  the  cerebellum.  This  question 
is  by  no  means  settled,  but  there  is  no  doubt  that  in  lesions  of  the  vermis 
itself  there  may  be  paresis  or  weakness  in  the  muscles  of  the  limbs  and 
especially  those  of  the  trunk,  and  in  lateral  lobe  lesions  weakness  has 
been  found  in  the  limbs  and  trunk  muscles  of  the  same  side.  This  can 
be  readily  seen  after  operations  upon  the  cerebellum  in  which  this 
organ  has  been  injured.  The  weakness  is  not  prominent  and  is  not 
always  present.  It  is  also  characteristic  of  cerebellar  disease  that  the 
limbs,  especially  on  the  side  of  the  lesion,  lose  their  accustomed  tone  and 
are  rather  flaccid.  This  symptom  is  also  by  no  means  constant,  and  is 
present  especially  in  lesions  of  the  vermis. 

The  gait  in  cerebellar  diseases  resembles  that  observed  in  a  drunken 
person.  The  patient  will  make  a  few  steps  and  then  will  totter  or  lurch 
to  one  side  or  the  other  or  backward  or  forward,  and,  recovering,  will 
repeat  this  over  again.  In  lesions  of  the  vermis  this  is  most  marked,  but 
in  lateral  lobe  and  in  extracerebellar  lesions,  in  which  the  former  is 
pressed  upon,  it  will  not  be  so  prominent.  Generally  the  patient  will 
have  a  tendency  to  walk  to  one  side,  usually  to  the  side  of  the  tumor, 
and  will  occasionally  have  a  tendency  to  fall  to  this  side.  If  such  a 
patient's  gait  were  not  corrected  he  would  tend  to  walk  in  a  circle,  the 
side  of  the  tumor  being  directed  toward  the  centre  of  the  circle.  The 
patient  is  generally  aware  of  this  tendency  to  walk  to  one  side,  and  in  his 
effort  to  correct  this  will  sometimes  walk  to  the  opposite  side. 

As  a  rule,  the  closure  of  the  eyes  will  not  tend  to  increase  the  inco- 
ordination if  the  lesion  is  in  the  vermis,  but  sometimes  in  lateral  lobe 
and  extracerebellar  lesions  the  gait  is  distinctly  made  worse  when  the 
eyes  are  closed. 

If  the  motor  columns  are  pressed  upon,  as  is  not  infrequent  in  extra- 
cerebellar lesions,  there  is  added  a  spastic  condition  on  the  side  opposite 
the  tumor.  A  bilateral  spastic  condition  is  also  often  present  when  there 
is  a  complicating  internal  hydrocephalus.  This  spasticity  to  a  certain 
extent  will  modify  the  incoordinate  gait. 

The  station  and  attitude  of  a  patient  with  cerebellar  disease  depends 
largely  upon  the  position  of  the  growth.  In  lesions  of  the  vermis  itself 
there  may  be  retraction  of  the  head  and  extension  of  the  lower  limbs 
with  flexion  of  the  upper.     There  may  also  be  lordosis  in  the  lower  por- 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES  181 

tion  of  the  spinal  column.  It  has  been  supposed  that  the  attitude  and 
position  of  the  trunk  and  head  are  considerably  modified  by  the  weak- 
ness which  is  supposed  to  be  present  in  the  erector  spinse  and  other  trunk 
muscles.  This  is  questionable,  for  the  alternate  contraction  of  these 
muscles  is  probably  only  an  effort  to  keep  the  parts  above  in  their  proper 
position,  and  is  only  a  part  of  the  general  incoordination.  Sometimes 
in  tumors  of  the  cerebellum  the  head  is  held  in  certain  positions  to  pre- 
vent the  growth  from  pressing  directly  upon  the  vermis.  In  tumors,  for 
instance,  of  the  left  lateral  lobe  the  patient  will  be  inclined  to  lie  on  his 
left  side,  for,  when  he  lies  on  the  right,  pressure  may  be  exerted  upon 
the  vermis.  This  symptom,  however,  is  not  by  any  means  constant. 
Very  often  also  patients  with  cerebellar  tumors  will  hold  their  heads  in 
abnormal  positions,  not  because  of  the  possible  influence  the  change  of 
position  would  have  upon  the  vertigo  and  dizziness,  but  because  they 
see  double  and  by  holding  their  heads  in  certain  positions  they  are  able 
to  avoid  this. 

If  the  patient  is  placed  with  his  feet  together  he  will  have  a  tendency  to 
fall,  generally  to  the  side  of  the  lesion.  As  a  rule,  if  the  eyes  are  closed, 
the  ataxia  will  be  increased,  and  this  is  especially  so  in  extracerebellar 
lesions. 

The  incoordination,  or  ataxia,  which  is  present  in  the  limbs  is  of  two 
types,  i.  e.,  it  may  be  made  worse  with  the  eyes  shut,  or  this  may  have  no 
influence  upon  it.  This  ataxia  is  dependent  upon  the  lack  of  coordina- 
tion in  the  muscular  contractions  and  is  not  dependent  upon  any  sensory 
disturbances.  As  a  rule,  it  is  greatest  on  the  side  of  the  lesion,  but  it 
may  also  be  observed  on  the  opposite  side.  If  the  upper  limb  on  the  side 
of  the  tumor  is  moved  in  any  direction,  for  instance,  as  in  supination  and 
pronation,  it  will  be  found  that  the  movement  will  not  be  so  well  nor  so 
rapidly  performed  as  upon  the  other  side.  The  same  thing  is  true  if 
the  lower  limb  is  moved.  These  symptoms  are  dependent  upon  the  lack 
of  coordinate  contraction  of  the  muscles  concerned  in  the  movements. 

Incoordination  in  the  movement  of  the  eyeballs,  or  nystagmus,  is  present 
nearly  always  in  lesions  of  the  cerebellum,  and  is  similar  to  that  observed* 
in  any  other  movement.  It  is  present  only  when  the  eyeballs  are  moved, 
and  is  greater  when  the  eyeballs  are  directed  to  the  side  of  the  lesion. 
The  nystagmus  may  consist  of  to-and-fro  jerkings  of  the  eyeballs  and  is 
greatest  in  lateral  deviation. 

Incoordinatiofi  of  the  muscles  ivhich  are  concerned  in  talking,  eating, 
and  swallowing  occurs  occasionally  in  lesions  of  the  middle  lobe  of  the 
cerebellum,  and  must  be  differentiated  from  the  difficulty  observed  when 
an  extracerebellar  tumor  presses  upon  the  cranial  nerves  supplying  the 
muscles  necessary  to  perform  these  acts. 

Cranial  Nerve  Symptoms.— The  cranial  nerves,  as  a  rule,  are  not 
involved  in  lesions  of  the  middle  lobe  of  the  cerebellum.  In  tumors  of 
the  lateral  lobe  it  is  possible  to  have  involvement  of  the  fifth,  sixth, 
seventh,  and  eighth  cranial  nerves  on  the  same  side,  but,  as  a  rule,  such 
cranial  nerve  involvement  indicates  a  tumor  in  the  angle  between  the 
pons  and  cerebellum,  or  the  cerebellopontile  angle. 


182  DISEASES  OF  THE  NERVOUS  SYSTEM 

The  first,  or  olfactory,  nerve  is  hardly  ever  diseased.  The  same  is  true 
so  far  as  the  third  and  fourth  cranial  nerves  are  concerned. 

The  fifth  cranial  nerve  may  sometimes  be  involved,  especially  in  extra- 
cerebellar  lesions.     Very  rarely  a  tumor  may  grow  from  this  nerve. 

Unilateral  involvement  of  the  sixth  nerve  is  a  very  common  symptom 
in  extracerebellar  lesions.  Bilateral  sixth  nerve  paralysis  may  some- 
times be  present  in  unilateral  lesions,  but,  as  a  rule,  this  indicates  a  tumor 
in  the  middle  lobe  or  the  vermis. 

The  seventh  nerve  is  nearly  always  involved  in  tumors  of  the  cere- 
bellopontile  angle,  and  a  fibroma  may  grow  from  this  nerve.  A  lateral 
cerebellar  tumor  may  sometimes  cause  involvement  of  this  nerve  by 
pressure. 

Tumors  of  the  cerebellopontile  angle,  as  a  rule,  grow  from  the  eighth 
nerve  and  are  generally  fibromata.  At  first  there  may  be  such  subjective 
symptoms  as  roaring,  hissing,  or  buzzing  noises  in  the  ear,  and  later 
complete  nerve  deafness.  This  nerve  may  be  involved  by  pressure  from 
a  growth  in  the  lateral  lobe  of  the  cerebellum. 

The  ninth,  tenth,  eleventh,  and  twelfth  nerves  may  be  involved  by 
pressure  from  extracerebellar  lesions,  causing  difficulty  in  talking,  eating, 
and  swallowing.  Bilateral  involvement  is  uncommon  and,  as  a  rule, 
indicates  a  lesion  in  the  medulla  itself. 

Pupillary  Symptoms. — ^Tumors  of  the  cerebellum  probably  have  no 
direct  effect  upon  the  condition  of  the  pupils,  alterations  in  them  probably 
depending  upon  the  presence  of  optic  neuritis  or  choked  disk. 

Motor  Symptoms. — The  weakness  or  paresis  which  is  sometimes 
present  in  cerebellar  lesions  has  already  been  discussed,  and  is  not  de- 
pendent upon  pressure  on  the  motor  columns.  An  extracerebellar  tumor 
usually  compresses  the  motor  fibers  of  the  pons,  and  this  causes  the  spastic 
condition  on  the  opposite  side  with  the  consequent  weakness,  increased 
reflexes,  and  the  presence  of  the  Babinski  phenomenon.  In  complicating 
internal  hydrocephalus  this  condition  may  be  bilateral. 

Lesions  of  the  cerebellum  usually  have  no  influence  upon  the  state 
of  the  reflexes^  which -may  be  increased,  lost,  or  in  normal  condition. 

Convulsions. — Convulsions^  either  general  or  limited,  sometimes  occur 
in  the  course  of  cerebellar  disease.  If  general,  as  sometimes  occurs  in 
lesions  limited  to  the  vermis,  there  is  retraction  of  the  head,  extension 
of  the  lower  limbs  and  flexion  of  the  upper,  and  the  whole  body  is  held 
in  tonic  contracture. 

Tumors  which  involve  the  seventh  nerve  may  cause  tremors  in  its 
distribution  and  sometimes  convulsions  which  are  limited  to  this  nerve 
and  are  focal  or  Jacksonian  in  character.  Instead  of  this  there  may 
occur  irregular  fainting  spells,  during  which  time  the  patient  feels  giddy 
and  has  a  tendency  to  fall.  These  are  not  really  convulsions  and  are 
dependent  upon  the  vertigo  common  in  this  disease. 

In  diagnosticating  tumors  of  the  posterior  cranial  fossa  it  is  necessary 
to  consider  whether  the  growth  is  cerebellar  or  extracerebellar,  and,  if 
the  former,  whether  the  tumor  is  localized  to  the  centre  or  to  the  lateral 
lobe  (Fig.  64). 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES 


183 


Summarizing  the  symptoms  of  a  tumor  in  the  vermis,  we  have  as  follows : 
headache  in  the  back  of  the  neck,  excessive  nausea  and  vomiting,  intense 
vertigo,  early  and  marked  bilateral  choked  disk;  marked  incoordination 
in  every  movement  of  the  body,  whether  in  the  limbs,  trunk,  movements 
of  the  eyeballs,  and  sometimes  in  articulation,  eating,  and  swallowing; 
sometimes  weakness  in  the  limbs  and  the  muscles  of  the  trunk  with  atonia, 
an  ataxic  gait,  poor  station,  and  rarely  so-called  cerebellar  fits,  during 
which  time  the  head  is  retracted,  the  legs  extended,  and  the  arms  flexed, 
all  in  tonic  contracture. 

Tumors  of  the  lateral  lobe  of  the  cerebellum  give  headache,  nausea, 
vomiting,  intense  vertigo,  early  and  marked  bilateral  choked  disk, 
which  may  be  greater  on  one  side,  incoordination  in  all  movements  of  the 
limbs  is  greater  on  the  side  of  the  lesion,  a  staggering  gait' with  a 
tendency  to  lurch  toward  the  affected  side,  nystagmus,  more  marked  in 


Fig.  64 


Tumor  of  the  fourth  ventricle,  causing  pressure  on  the  middle  and  lateral  lobes  of  the  cerebeljum. 
There  was  cerebellar  incoordination  of  the  whole  body  and  an  ataxic  drunken  gait,  some  weak- 
ness in  the  limbs,  headache,  excessive  dizziness,  nausea,  vomiting,  and  choked  disk. 


looking  toward  the  side  of  the  lesion,  sometimes  paresis  and  atonia  in 
the  limbs  of  the  same  side,  and,  if  the  tumor  is  large  pressure  upon  the 
cranial  nerves  of  the  same  side. 

Extracerebellar  lesions  may  arise  either  in  the  angle  between  the  pons 
and  the  medulla,  i.  e.,  the  so-called  cerebellopontile  angle,  or  may  grow 
from  the  occipital  or  temporal  bone  primarily,  and  secondarily  involve 
the  structures  in  the  cerebellopontile  angle  and  the  cerebellum  itself. 

Tumors  of  the  cerebellopontile  angle  are  usually  fibromata  and  grow 
from  the  eighth,  seventh,  fifth,  and  sixth  nerves  in  order  of  frequency,  and 
the  first  symptom  will  depend  upon  which  nerve  is  involved.  If  the 
growth  is  on  the  eighth  nerve,  there  is  first  a  roaring,  buzzing,  or  hissing 
noise  on  the  side  of  the  tumor,  to  be  followed  by  deafness  and  then  the 
symptoms  of  paralysis  of  the  seventh  and  sixth  nerves,  and  more  rarely  of 
the  fifth  nerve,  as  these  nerves  are  pressed  upon.  There  are,  in  addition, 
headache,  nausea,  vomiting,  vertigo,  which  may  be  excessive  if  the  eighth 


184 


DISEASES  OF  THE  NERVOUS  SYSTEM 


nerve  is  diseased,  and  choked  disk,  which,  as  a  rule,  is  greater  on  the  side 
of  the  tumor.  When  the  cerebelhim  is  pressed  upon  there  are  added 
incoordinate  symptoms  in  the  hmbs,  greater  on  the  side  of  the  lesion, 
paresis,  and  atonia,  only  rarely  on  the  side  of  the  tumor,  a  staggering  and 
incoordinate  gait  to  the  side  of  the  tumor,  and  less  frequently  nystag- 
mus, which  is  greater  when  the  eyes  are  deviated  to  the  affected  side. 
If  the  tumor  grows  from  the  seventh  nerve,  spasms  in  its  distribution 


Fig.  65 


Fibroma  growing  from  the   left  acoustic  nerve  compressing  slightly  the  left  lateral  lobe  of  the 
cerebellum  and  the  lower  surface  of  the  left  temporal  lobe. 


maybe  observed.  As  a  rule,  the  growth  will  press  upon  the  motor  fibers 
of  the  pons,  causing  weakness  and  spasticity  with  increase  of  reflexes  in 
the  limbs  of  the  opposite  side  (Fig.  65). 

If  the  tumor  grows  from  the  dura  covering  the  occipital  or  the  temporal 
bone,  the  symptoms  may  be  a  little  more  diffuse,  being  the  same  as  those 
above  enumerated  in  tumors  of  the  cerebellopontile  angle  plus  involve- 
ment of  some  of  the  cranial  nerves  on  the  opposite  side. 

Sometimes  diffuse  syphilitic  lesions  in  various  portions  of  the  brain  or 
a  pial  infiltration  at  the  base  of  the  brain  may  give  the  symptoms  of  a 
cerebellar  tumor  to  such  an  extent  that  it  is  almost  impossible  to  make  a 
differential  diagnosis.     There  may  be  present  all  of  the  general  symp- 


DISEASES  OF  THE  BRAIN  AND  ITS  MENINGES  185 

toms  of  a  cerebellar  lesion,  but  there  will  be  in  addition  almost  always 
a  greater  involvement  of  the  cranial  nerves,  such  as  that  of  the  third,  a 
very  unusual  condition  in  pure  cerebellar  or  extracerebellar  lesions. 
Multiple  sarcomatous  tumors  may  also  give  the  symptoms  of  a  tumor 
in  the  cerebellum  or  of  the  angle,  and  in  such  instances  it  is  almost  impos- 
sible to  differentiate  the  symptoms  from  those  resulting  from  basal 
syphilis. 

Injuries  to  the  Brain. — This  subject  is  fully  discussed  elsewhere 
(p.  223).  As  a  rule,  if  the  injury  is  severe  enough  there  will  be  impair- 
ment of  consciousness.  If  this  is  complete,  so  that  the  patient  cannot 
be  aroused,  it  is  called  coma.  If  the  patient  can  be  aroused  so  that 
questions  are  answered,  it  is  called  stupor;  whereas  an  expression 
of  wandering  ideas  accompanied  by  stupor  is  called  delirimn.  No 
matter  how  slight  the  injury,  there  may  be  an  accompanying  fright 
which  leaves  its  mental  impression,  and  furnishes  one  of  the  causes 
of  the  traumatic  neuroses.  In  those  cases  in  which  unconsciousness 
results  from  the  injury,  if  the  patient  rallies,  this  element  of  functional 
disturbance  may  enter.  Its  influence  will  be  discussed  under  the  head 
of  traumatic  neuroses. 

In  most  instances  the  period  of  unconsciousness  will  not  last  long,  and 
the  patient  will  rally  within  a  few  hours,  but  sometimes  the  stupor 
may  persist  for  a  number  of  days  and  even  longer.  It  is  possible  for  the 
patient  to  regain  consciousness  and  again  lapse  into  stupor,  especially 
when  there  is  a  progressive  hemorrhage.  As  a  rule,  if  the  patient  rallies 
within  a  few  or  less  than  twenty-four  hours  the  prognosis  is  good,  whereas 
stupor  lasting  for  more  than  a  day  will  make  the  prognosis  very  grave. 
It  is  necessary  in  a  great  many  instances  to  diagnosticate  such  a  comatose 
condition  from  those  arising  in  alcoholism,  uremia,  diabetes,  and  hysteria. 
There  should,  however,  not  be  much  difficulty  in  making  a  differential 
diagnosis  if  the  underlying  causes  are  considered. 

Certain  general  symptoms  may  always  be  present  whenever  con- 
siderable compression  of  the  brain  from  any  cause  exists.  They  are 
alterations  in  consciousness,  disturbances  in  respiration  and  pulse, 
specific  symptoms,  as  paralysis,  depending  entirely  upon  the  position 
of  the  lesion;  nausea,  vomiting,  vertigo,  and  choked  disk.  The  severity  of 
these  symptoms  will  depend  upon  the  rapidity  of  onset  and  the  extent 
of  the  pressure.  In  those  cases  in  which  the  pressure  is  sudden,  such 
as  from  large  hemorrhage,  the  symptoms  will  be  marked  and  prompt, 
whereas  in  slow  bleeding  they  will  develop  slowly. 

The  most  important  factor  in  the  prognosis  is  the  state  of  the  respira- 
tion and  pulse.  Disturbance  in  respiration  is  an  early  symptom  of  com- 
pression, and  there  may  be  slowing  in  the  rate,  arhythmical  or  stertorous 
breathing  or  the  typical  Cheyne-Stokes  type,  the  occurrence  of  the  latter 
nearly  always  affording  a  grave  prognosis.  The  pulse  in  cerebral  com- 
pression is  nearly  always  slow,  its  rate  sometimes  being  as  low  as  40 
to  the  minute.  The  blood  pressure  usually  is  high,  and  when  meas- 
ured by  the  Stanton  apparatus  it  may  be  250  or  more.  The  increase 
in  the  peripheral  blood  pressure  is  an  attempt  of  Nature  to  equalize  the 


186  DISEASES  OF  THE  NERVOVS  SYSTEM 

lessened  pressure  within  the  cranial  cavity,  and  therefore  such  procedure 
as  peripheral  bleeding  is  contra-indicated.  A  temperature  of  105°  to 
107°  is  a  not  infrequent  precursor  of  a  lethal  termination. 

Fracture  of  the  Base  of  the  Skull. — (See  p.  228.)  It  is  upon  the  focal 
symptoms  that  the  diagnosis  of  fracture  of  the  base  must  be  made. 
This  will  depend  upon  the  line  of  fracture  and  upon  the  possible  exist- 
ence of  a  hemorrhage.  In  nearly,  all  cases  some  of  the  cranial  nerves 
will  be  involved,  and  of  these  the  optic  and  the  sixth,  seventh,  and 
eighth  nerves  are  most  commonly  the  seat  of  injury. 

The  first,  or  olfactory,  nerve  is  frequently  involved  from  a  fracture  in 
any  portion  of  the  skull,  probably  because  of  injury  to  the  ethmoid, 
unilateral  or  bilateral  loss  of  smell,  and  impairment  of  taste  resulting. 

The  second,  or  oiptic,  nerve  is  very  frequently  injured,  either  on  one  or 
both  sides.  This  may  be  either  because  of  a  hemorrhage  in  or  about  the 
optic  chiasm,  or,  what  is  more  frequently  the  case,  because  of  fracture 
through  the  optic  foramina.  The  impairment  of  sight  will  depend  upon 
whether  one  or  both  optic  nerves  are  diseased  and  upon  the  part  of  the 
nerve  which  is  injured.  Very  frequently  there  will  be  neither  fracture 
through  the  optic  foramina  nor  hemorrhage  involving  the  optic  nerve,  but 
a  momentary  pinching  of  the  nerves.  Whether  this  causes  a  hemorrhage 
into  the  sheath  or  into  the  nerve  itself,  or  whether  it  causes  a  destruction 
of  fibers  with  a  consequent  atrophy,  is  not  known,  but  the  fact  remains 
that  such  pinching  will  in  many  cases  result  in  a  diminution  and  some- 
times total  loss  of  vision.  In  rare  instances  it  is  possible  to  have  such  an 
injury  of  the  optic  nerve  with  consequent  optic  atrophy  without  any  other 
symptom,  and  more  rarely  still  this  impairment  of  vision  may  be  in  the 
form  of  irregular  hemianopsia. 

The  third,  or  oculomotor,  nerve  is  rarely  involved,  but  suffers  when 
there  is  a  fracture  through  the  orbit  and  the  middle  cranial  fossa.  The 
lesion  may  be  unilateral  or  bilateral.  In  most  instances  only  part  of 
the  distribution  of  the  oculomotor  nerve  is  paralyzed,  this  resulting 
in  drooping  of  the  upper  lid  or  possibly  a  weakness  of  some  of  the 
ocular  muscles. 

The  fourth  nerve  is  only  rarely  diseased  in  injuries  of  the  brain.  The 
fifth  nerve  is  sometimes  involved  in  fracture  of  the  middle  cranial  fossa, 
but  its  involvement  is  also  rare. 

The  sixth,  seventh,  and  eighth  nerves  are  probably  more  frequently 
involved  in  fractures  of  the  base  than  the  other  cranial  nerves,  and, 
because  the  exits  of  these  nerves  at  the  base  are  so  close  together,  they 
are  often  simultaneously  affected. 

Very  rarely  the  ninth,  tenth,  eleventh,  and  twelfth  cranial  nerves 
are  injured,  causing  difficulty  in  eating,  talking,  and  swallowing  and 
irregularity  of  the  pulse  and  respiration.  These  are  only  present  in 
severe  cases  and  nearly  always  result  fatally. 

It  is  characteristic  of  these  cranial  nerve  palsies  that  they  are  not  of 
permanent  duration,  for  in  most  instances,  if  the  patient  lives,  a  partial 
and  sometimes  a  total  recovery  may  be  expected. 

Sometimes  there  results  in  fracture  of  the  base  of  the  skull  hemor- 


DISEASES  OF  THE  SPINAL  CORD  187 

rhage  from  one  of  the  basal  arteries.  The  symptoms  of  this  will  depend 
entirely  upon  the  place  of  hemorrhage  and  upon  the  structures  com- 
pressed. In  most  instances  the  hemorrhage  is  in  or  about  the  optic 
chiasm,  this  causing  paralysis  of  the  ocular  muscles  and  impairment  of 
vision,  and,  if  the  hemorrhage  is  large  enough,  the  general  symptoms  of 
compression,  such  as  headache,  nausea  and  vomiting,  and  choked  disk. 

k^ummarizing  then  the  symptoms  of  fracture  of  the  base  of  the  skull, 
there  may  be  either  coma,  stupor,  or  delirium,  which  may  last  a  few  to 
twenty-four  hours  or  a  number  of  days  and  from  which  the  patient  may 
or  may  not  rally,  stertorous  respiration,  slow,  irregular  pulse,  bleeding 
from  the  nose,  throat,  or  ear,  sometimes  the  escape  of  cerebrospinal  fluid, 
subconjunctival  or  subcutaneous  ecchymosis,  and  paralysis  of  some  of  the 
cranial  nerves  with  irregular  pupils.  If  there  is  an  accompanying  hemor- 
rhage into  the  substance  of  the  brain,  the  symptoms  will  depend  upon 
whether  the  motor,  sensory,  or  special  fibers  are  involved;  if  there  is  a 
fracture  of  the  vault,  the  additional  symptoms  of  this. 

The  prognosis  will  depend  upon  the  extent  of  the  cranial  nerve  in- 
volvement, whether  or  not  there  are  hemorrhages  in  the  brain  substance, 
and  upon  the  stupor  and  the  state  of  the  respiration  and  pulse.  The 
prognosis  is  always  best  where  the  patient  rallies  within  a  few  or  twenty- 
four  hours,  and  the  state  of  the  pulse  is  the  best  indication  of  the  results 
to  be  expected. 

Terminal  Effects  of  Injuries  to  the  Brain. — These  will  depend  largely 
upon  the  character  of  the  injury  and  its  effects  and  the  benefit  of  what- 
ever therapeutics  have  been  employed.  Injuries  to  the  skull  such  as  will 
involve  the  meninges  and  brain  are  among  the  most  frequent  causes  of 
traumatic  epilepsy.  If  the  injury  is  over  the  motor  area,  Jacksonian 
convulsions  may  result,  but  very  often  injury  anywhere  in  the  brain, 
especially  if  this  occurs  in  the  young,  may  be  followed  by  general  or 
idiopathic  epilepsy.  Such  other  effects  as  hemiplegia  or  diplegia  and 
impairment  of  vision  and  sensation  need  no  further  discussion. 

The  mental  symptoms  are  by  far  the  most  important.  Very  often  a 
trivial  injury  will  cause  a  change  in  the  disposition  of  the  individual  and 
produce  more  or  less  irregular  headache,  dizziness,  lack  of  attention  to 
business  details,  with  the  addition  of  many  functional  symptoms  which 
will  be  discussed  later. 

It  is  also  a  mooted  question  whether  injuries  to  the  brain  can  produce 
insanity.  It  is  probable  that  in  very  rare  instances  it  may  cause  the 
earlier  appearance  of  insanity  where  there  has  been  a  predisposition  for  it, 
but  it  is  hardly  possible  that  direct  injury  to  the  brain  can  cause  insanity. 
There  is  no  denying,  however,  that  mental  impairment  is  not  of  infre- 
quent occurrence. 

DISEASES  OF  THE  SPINAL  CORD. 

Anatomical  Relations. — The  spinal  cord  is  situated  in  the  spinal 
canal  and  extends  from  the  lower  portion  of  the  medulla  oblongata  to 
a  point  opposite  the  upper  border  of  the  second  lumbar  vertebra.     It 


188 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Dura 


achnoid 
Dorsal  root 
Ventral  root 


consists  of  eight  cervical,  twelve  thoracic,  five  lumbar,  and  five  sacral 
segments.  The  cord  is  composed  of  gray  and  white  matter,  the  former 
being  in  the  centre  and  surrounded  by  white  matter.  The  gray  matter  is 
divided  equally  on  both  sides  of  the  spinal  cord  and  is  connected  by  a 
commissure  and  consists  of  an  anterior  and  a  posterior  horn.  It  is  com- 
posed of  nerve  cells  and  their  dendritic  processes,  axis  cylinders,  nerve 
fibers,  and  neurogliar  tissue  which  holds  these  structures  in  place.  The 
white  matter  consists  of  nerve  fibers  and  neurogliar  and  connective 
tissue,  besides  arteries,  veins,  and  lymphatic  vessels  throughout  the  whole 
spinal  cord.  The  nerve  fibers  which  are  situated  in  the  white  matter 
are  bound  together  in  bundles  or  tracts,  each  of  which  has  a  definite 
function.  Normally  these  cannot  be  differentiated;  it  is  necessary  to 
have  pathological  processes  or  what  is  called  secondary  degeneration  to 
bring  out  the  different  tracts  (Fig.  66). 

From  the  nerve  cells  situated  in 
^i<^-  66  the   gray   matter  of   the   anterior 

horn  come  the  so-called  anterior 
roots  which  are  motor  in  func- 
tion. The  posterior  roots  enter 
into  the  spinal  cord  in  an  area 
called  the  entrance  root  zone,  this 
being  in  the  inner  surface  of  the 
posterior  horn  of  the  gray  matter. 
The  fibers  transmitted  by  the 
posterior  roots  come  from  the 
periphery  and  ascend  into  the 
spinal  cord,  and  are  sensory  in 
function.  On  each  posterior  root 
is  situated  a  collection  of  nerve 
cells  called  the  posterior  root  gan- 
glion. The  anterior  and  the  pos- 
terior root  then  join  together  to  form  one  nerve  which  goes  through  the 
dura.  Each  spinal  segment  has  a  pair  of  anterior  and  a  pair  of 
posterior  roots  which  form  two  nerves  coming  off  from  the  right  and 
the  left  side  of  the  cord. 

The  spinal  cord  is  surrounded  by  the  pial  sheath  and  is  held  in  place 
by  the  anterior  and  the  posterior  roots  and  connective-tissue  septa  and 
by  the  cerebrospinal  fluid,  these  structures  being  attached  to  and  sur- 
rounded by  the  dura,  which  in  turn  is  held  in  place  in  the  spinal  canal 
by  the  attached  peripheral  nerves  (Fig.  67). 

Spinal  Roots. — The  anterior  and  posterior  roots  travel  within  the  dura 
for  various  lengths  before  they  join  to  form  a  peripheral  nerve.  It  is 
necessary  to  know  the  place  of  exit  of  each  nerve  root,  and  an  easy  way 
to  remember  it  is  that  every  nerve  root  leaves  the  spinal  canal  at  the  bot- 
tom of  the  corresponding  vertebra;  thus,  the  second  lumbar  root  leaves 
at  the  bottom  of  the  second  lumbar  vertebra.  There  is  an  exception, 
however,  so  far  as  the  cervical  roots  are  concerned.  There  are  eight 
cervical  segments  and  only  seven  cervical  vertebrae,  so  that  the  eighth 


alia 


Plexus  venoisvs 


Transverse  section   of  the  spinal  cord  and  its 
membranes.     (Gegenbauer.) 


DISEASES  OF  THE  SPINAL  CORD 


189 


Fig.  G7 

N.  to  7-ectus  lateralis 

Uto  rectus  antic,  minor 

inastoniosis  with  hypoglossal 

Anastomosis  with  pnevmogastrie 

iS'.  to  rectus  antic.majo): 

'_ iY.  to  mastoid  region. 

Great  auricular  a. 

Transverse  cervical  n. 
=r==;^[jY.  to  Trapezius,  Any.  Scap.  and  Rhomboid. 

Supra-aaiicular  n. 

Supra-acroiulai  n. 

Phrenic  u. 

N.  to  levator  ang.  scap. 

S<.  to  rhomboid 

Subscapular  n. 

Subclavicular  71. 


X.  to  peetoralis  major. 


Circumflex  n, 

Musculo-cutaneous  n. 

Median  n. 

Radial  n. 

Ulnar  n. 

Internal  cutaneous  n. 

Sinall  internal  cutaneous  n. 


Ilio-hypogastric  n. 

.llio-inguinal  n. 


External  cutaneous  n, 
Qenito-crural  n. 


Anterior  crural  n. 


N.  to  levator  ani. -^ct^ 

•Y.  to  obturator  int. j^ 

y.  to  sphincter  ani . 

Coccygeal  n. 


Superior  gluteal  n. 


.N.  to  pyrifonnis 
.N.  to  gemellus  super. 


Small  sciatic  n. 
Sciatic  n. 


Tlie  relation  of  the  segments  of  the  spinal  cord  and  their  nerve  roots  to  the  bodies  and  spines 
of  the  vertebrse.     Dejerine  at  Thomas,  Mai.  d.  1.  Moelle  Epinifere,  Paris,  1902.) 


190 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Fig.  68 


cervical  root  leaves  at  the  bottom  of  the  seventh  cervical  vertebra,  and  the 
first  at  the  top  of  the  first  cervical  vertebra,  or  atlas.  The  end  of  the  cord 
is  opposite  the  upper  border  of  the  second  lumbar  vertebra.  The  course 
of  the  cervical  roots  in  the  spinal  canal  before  their  exit  is  very  short. 
It  is  longer  for  the  thoracic  roots  and  still  longer  for  the  roots  from  the 
lowest  portion  of  the  spinal  cord;  thus,  the  second  lumbar  root  has  a 
course  of  three  or  four  inches  within  the  spinal  canal  (Fig.  68). 

Spinal  Segments. — It  is  also  necessary  from  the  surgical  point  of  view 
to  know  the  relations  of  the  different  spinal  segments  to  the  vertebrae. 
This,  however,  is  not  definite  and  cannot  be  fixed  by  any  rule,  and  refer- 
ence, therefore,  must  always  be  made  to  charts. 
It  should  be  remembered,  however,  that  the 
spinal  cord  ends  opposite  the  upper  border  of 
the  second  lumbar  vertebra,  and  that  some- 
times in  children  it  is  a  little  lower.  The  end 
of  the  spinal  cord  is  called  the  filum  terminale. 
Functions. — The  spinal  cord  has  two  func- 
tions: one,  to  conduct  impulses  to  and  from 
the  brain;  and  second,  in  it  are  nerve  cells 
which  control  the  motor  and  trophic  functions 
of  the  limbs,  chest,  and  abdomen.  A  better 
understanding  of  the  cerebrospinal  system  will 
be  had  if  it  is  remembered  that  there  are  two 
sets  of  centres  in  the  nervous  system,  and  that 
in  the  higher,  or  in  the  cerebrum,  is  represented 
the  centre  for  every  motion,  sensation,  and 
special  act,  in  this  being  included  also  the 
cerebellum;  and  that  in  the  lower  centres,  in 
which  are  included  the  crus,  pons,  medulla, 
and  spinal  cord,  is  represented  the  whole  sur- 
face of  the  body.  For  instance,  in  the  crus, 
pons,  and  medulla  there  are  collections  of  nerve  cells,  or  nuclei,  which  are 
concerned  with  the  innervation  of  the  movements  of  the  face,  eyes,  nose, 
and  throat,  and  eating,  talking,  and  swallowing,  whereas  in  the  spinal 
cord  the  collections  of  nerve  cells  in  the  anterior  horns  are  concerned  with 
the  movements  of  the  limbs,  trunk,  and  abdomen,  and  that  the  peripheral 
nerves  which  connect  the  peripheral  musculature  with  the  spinal  cord 
have  exactly  the  same  function  that  the  cranial  nerves  have  which 
connect  their  musculature  with  the  nuclei  in  the  crus,  pons,  and  medulla. 
Localization. — There  are  two  enlargements  of  the  spinal  cord,  the 
so-called  cervical  and  lumbar.  This  is  because  the  cells  in  these  parts 
innervate  the  muscles  of  the  upper  and  lower  limbs  respectively,  the 
cervical  enlargement  beginning  in  the  fourth  and  including  the  fifth, 
sixth,  seventh,  and  eighth  cervical  and  first  thoracic  segments,  whereas 
the  lumbar  enlargement  begins  in  the  first  lumbar  segment  and  includes 
the  second,  third,  fourth,  and  fifth  lumbar.  From  here  on  the  spinal 
cord  gradually  tapers  off.  That  part  of  the  cord  which  includes  the 
second,  third,  fourth,  and  fifth  sacral  is  called  the  conus  meduUaris,  and 
just  above  this  and  including  the  fifth  lumbar  and  first  and  second  sacral 


Formation  of    a   spinal    nerve 

(Testut.) 


PLATE    VIII 


Areas  of  Anassthesia  upon  the    Body  after    Lesions  in  the    Various 
Segments  of  the  Spinal  Cord.      (Starr.) 

The  segments  of  the  cord  are  numbored:  C  I  to  VIII,  D  I  to  XII,  L  I  to  V,  S  1  to  5,  and  these  numbers 
are  placed  on  the  region  of  the  skin  supplied  by  the  sensory  nerves  of  the  corresponding  segment. 


DISEASES  OF  THE  SPINAL  CORD 


191 


segments  is  the  so-called  epiconus.  The  nerve  roots  coming  from  the 
lumbar  and  sacral  cords,  when  taken  together,  have  been  called  the  cauda 
equina,  from  their  resemblance  to  a  horse's  tail. 

Motor  Functions.- — The  nerve  cells  situated  in  the  gray  matter  of  the 
anterior  horns  innervate  directly  the  peripheral  musculature,  and  it  is 
probable  that  a  number  of  nerve  cells  are  concerned  with  each  fiber.  It 
is  necessary  to  know  which  cells  are  concerned  with  the  innervation  of 
each  muscle. 


Showing  the  Muscles  Represented  in  Groups  of  Cells  in  the  Various  Segments 

of  the  Spinal  Cord. 


IL  and  III. 

IV. 

v. 

VI. 

VII. 

VIII. 

I. 

Cervical. 

Cervical. 

Cervical. 

Cervical. 

Cervical. 

Cervical. 

Dorsal. 

Diaphragm. 

Diaphragm. 

Sterno- 

Lev.ang.scap. 

mastoid. 

Rhomboid. 

Rhomboid. 

Trapezius. 

Supra-  and 

Supra-  and 

Scalenus. 

1 

infraspin. 
Deltoid. 
Supin.  long. 
Biceps. 

infraspin. 
Deltoid. 
Supin.  long. 
Biceps. 
Supin.  brev. 
Serratus  mag. 
Pect.  (clav.). 
Teres  minor. 

Biceps. 

Serratus  mag. 
Pect.  (clav.). 
Pronators. 
Triceps. 
Brach   ant. 
Long  exten- 
sors of  wrist. 

Pronators. 

Triceps. 

Brach.  ant. 

Long  exten- 
sors of  wrist 
and  fingers. 

Pect. (costal). 

Latis.  dorsi. 

Teres  major. 

Long  flexors 
of  wrist  and 
fingers. 

Long  flexors 
of  wrist  and 
fingers. 
Extensor  of 

thumb. 
Intrinsic 
muscles  of 
hands. 

Extensor  of 

thumb. 
Intrinsic 

muscles  of 

hands. 

I.    Lumbar. 

II.    Lumbar. 

III.    Lumbar. 

IV.    Lumbar. 

V.    Lumbar. 

Quadr.  lumb. 

Obliqui. 

Transversalis. 

Psoas. 

Psoas. 

Iliacus. 

Iliacus. 
Sartorius. 
Quad.  ext.  cruris. 

Quad.  ext.  cruris. 

Obturator. 

Adductores. 

Obturator. 

Adductores. 

Glutei. 

Glutei. 

Biceps  femoris. 
Semitend. 
PopUteus. 

I.    Sacral. 


Biceps  femor. 
Semimemb. 
Ext.  long.  dig. 
Gastroc. 
Tibialis  post. 


II.    Sacral. 


Gastroc. 

Tibialis  post. 

Tibialis  anticus. 

Peronei. 

Intrinsic  muscles  of  foot. 


III.    Sacral. 


Peronei. 

Intrinsic  muscles  of  foot. 


IV.  and  V.  Sacral. 


Sphincter  ani  et  vesicae. 
Perineal  muscles. 


192 


DISEASES  OF  THE  NERVOUS  SYSTEM 


It  will  be  seen  from  this  that  we  do  not  know  exactly  this  localization 
and  that  approximately  every  muscle  has  a  representation  in  the  nerve 
cells  of  one  or  two  segments.  Should  there  be  a  lesion  destroying  the  cells 
supplying  any  muscle  or  group  of  muscles,  there  will  necessarily  be  loss  of 
power,  and  as  these  nerve  cells  are  also  trophic  in  function  there  will  be 
in  addition  atrophy  and  loss  of  tone  or  flaccidity  in  the  related  parts. 
Besides,  in  the  performance  of  every  movement  we  have  a  sensory  irrita- 
tion or  impulse,  a  centre  for  which  is  in  the  nerve  cells,  and  a  peripheral, 
or  motor,  response;  this  is  the  so-called  reflex  arc,  and  an  interference  with 
it  will  cause  a  loss  of  any  form  of  reflex.    Summarizing,  then,  the  symp- 


FiG.  69 


Columns  of  the  cord. 

toms  of  a  lesion  destroying  the  cells  of  the  anterior  horn,  there  will  be 
loss  of  power  or  paralysis  in  the  related  muscles,  atrophy,  loss  of  tone,  or 
flaccidity,  loss  of  reflexes,  and  electrical  reactions  of  degeneration.  Such 
is  the  case  in  acute  anterior  poliomyelitis,  or  acute  infantile  spinal  palsy. 
Should  there  be  a  slow  or  chronic  degeneration  of  the  cells  in  the  anterior 
horn  such  as  occurs  in  chronic  poliomyelitis  there  will  result  fibrillary 
tremors  in  the  related  muscle  fibers,  gradual  atrophy  and  loss  of  power, 
loss  of  reflexes,  and  gradual  reactions  of  degeneration. 

The  second  function  of  the  spinal  cord  is  that  of  conduction  of  impulses 
either  from  or  to  the  brain.  These  are  transmitted  by  means  of  the 
different  tracts  situated  in  the  white  matter  of  the  spinal  cord  (Fig.  69). 


DISEASES  OF  THE  SPINAL  CORD  193 

The  motor  functions  are  transmitted  from  the  motor  cortex  by  means  of 
the  crossed  and  the  direct  pyramidal  tract.  For  instance,  the  right  crossed 
pyramidal  tract  comes  from  the  left  motor  cortex,  the  decussation  having 
taken  place  in  the  medulla.  From  the  pyramidal  tracts  these  fibers 
probably  go  to  the  cells  of  the  anterior  horn  of  the  spinal  cord  of  the  same 
side  and  from  these  cells  come  the  anterior  roots  and  from  the  anterior 
roots  the  motor  part  of  the  peripheral  nerves.  A  lesion  of  the  motor 
columns  causes  weakness,  spasticity,  increased  reflexes,  and  the  Babinski 
phenomenon.  If  the  lesion  involves  the  pyramidal  tracts  above  the 
cervical  cord,  these  symptoms  are  present  in  both  the  upper  and  lower 
limbs,  but,  if  the  lesion  is  below  the  cervical  enlargement,  it  is  only  possible 
to  have  these  symptoms  in  the  lower  limb  on  the  same  side. 

Sensory  Functions. — The  sensory  fibers  which  enter  the  spinal  cord 
by  means  of  the  posterior  roots  take  various  courses  after  their  entrance. 
Those  fibers  which  are  concerned  with  touch  sensation  and  so-called 
muscle  sense  ascend  on  the  same  side  of  the  spinal  cord  and  are  first 
situated  in  the  column  of  Goll  and  then  are  pushed  into  the  column  of 
Burdach  by  the  fibers  entering  higher  up,  decussating  in  the  medulla 
just  above  the  motor  decussation.     They  then  go  into  the  sensory  cortex. 

Those  fibers  which  are  concerned  in  the  transmission  of  sensation  for 
pain  and  temperature  enter  the  gray  matter  of  the  posterior  horn, 
decussate  almost  immediately  in  it  and  travel  upward  in  the  spinal  cord 
in  the  so-called  column  of  Gowers.  The  fibers  which  transmit  touch, 
pain,  and  temperature  sensations  after  their  respective  decussations  in 
the  medulla  and  spinal  cord  are  transmitted  by  means  of  the  median 
fillet  to  the  optic  thalamus  of  the  same  side,  and  then  through  the  posterior 
portion  of  the  posterior  limb  of  the  internal  capsule  to  the  cortical  sen- 
sory centres  in  the  postcentral  convolution  of  the  same  side. 

If  a  disease  involves  a  posterior  root  and  destroys  its  fibers,  there  will 
be  loss  of  all  forms  of  sensation  in  the  parts  which  these  fibers  supply. 
The  skin  areas  of  sensation  which  are  in  relation  to  a  posterior  root  are 
fairly  well  known  and  run  in  bands  lengthwise  in  the  limbs  and  in  the 
chest  and  abdomen  horizontally.  It  is  necessary  to  distinguish  the  area 
of  sensation  in  relation  with  a  certain  root  from  that  of  the  segment 
which  this  root  supplies.  In  the  former  the  disturbance  of  sensation 
will  always  be  unilateral,  while  in  a  lesion  involving  any  segment  of 
the  spinal  cord  the  disturbance  of  sensation  must  be  bilateral.  It  is 
probable  that  sensation  in  any  part  of  the  limbs  or  of  the  chest  and 
abdomen  is  in  relation  with  more  than  one  root  or  segment  and  in  a 
lesion  which  destroys  only  one  root  or  segment  the  loss  of  sensation 
will  be  very  limited. 

Bladder,  Rectal,  and  Sexual  Centres. — In  the  second,  third,  and  fourth 
sacral  segments  are  situated  the  centres  for  bladder,  rectal,  and  sexual 
functions  and  a  destruction  of  this  part  of  the  cord  will  cause  a  loss  of 
these  functions.  It  seems  also  that  the  fibers  concerned  with  the  bladder 
and  rectal  functions  descend  in  the  lateral  columns  of  the  spinal  cord, 
and  that  lesions  in  these  tracts  may  cause  an  impairment  in  their  func- 
tions. 

13 


194  DISEASES  OF  THE  NERVOUS  SYSTEM 

It  is  not  the  object  of  this  chapter  to  discuss  every  disease  of  the  spinal 
cord,  but,  inasmuch  as  tumors  or  injuries  may  involve  part  or  all  of 
the  cord,  it  will  be  necessary  to  be  able  to  diagnosticate  a  lesion  in  any 
part  To  make  the  subject  clearer  the  symptoms  of  different  diseases 
and  possible  lesions  will  be  given. 

Fig.  70 


Atrophy  of  left  upper  limb  and  shoulder  in  acute  anterior  poliomyelitis. 

Diseases  Involving  the  Cells  of  the  Anterior  Horn. —Acute  Anterior 
Poliomyelitis.  Infantile  Palsy. — A  disease  of  infancy  characterized  by 
sudden  onset,  with  or  without  fever,  flaccid  paralysis  of  one  or  all^  of  the 
limbs,  followed  by  atrophy,  loss  of  reflexes,  and  electrical  reactions  of 
degeneration. 

The  disease  usually  appears  in  a  child  previously  well,  and  rarely  in  the 
course  of  or  following  an  infectious  disease,  such  as  scarlet  fever,  measles. 


DISEASES  OF  THE  SPINAL  CORD  195 

or  smallpox.  It  usually  occurs  sporadically,  but  within  recent  years 
epidemics  have  been  frequent,  especially  in  the  States  of  Pennsylvania 
and  New  York.  Several  members  of  the  same  family,  people  of  certain 
localities,  and  lower  animals,  such  as  pigs  and  chickens,  may  become 
diseased,  leading  to  the  belief  that  the  disease  is  probably  infectious  or 
that  it  may  be  transmitted  through  the  water  or  soil  (Fig.  70). 

Symptoms. — The  disease  usually  appears  in  the  infantile  period,  gen- 
erally between  the  ages  of  one  and  three  years,  although  it  may  occur 
later  in  life,  especially  in  epidemics.     Rarely  it  may  occur  in  adults. 

It  is  usually  ushered  in  by  fever  with  its  accompanying  symptoms  of 
malaise  and  chilliness,  or  the  child  may  have  felt  sick  for  only  a  day  or 
so  when  the  weakness  or  paralysis  is  discovered.  At  first  it  is  quite 
extensive  and  may  affect  all  of  the  limbs,  but,  as  a  rule,  it  involves  by 
preference  one  or  both  lower  limbs.  Within  a  few  days  to  four  or  five 
weeks  the  extent  of  the  paralysis  gradually  lessens  and  there  remains 
what  is  called  a  residual  palsy.  The  muscles  of  the  limbs  are  never  all 
paralyzed,  but  there  seems  to  be  a  predilection  for  certain  groups,  as,  for 
instance,  in  the  leg,  the  anterior  tibial  and  the'peroneal.  Because  of  this 
unequal  paralysis  contractures  of  various  types  result.  The  paralysis  is 
always  flaccid  in  type  and  it  is  possible  to  passively  move  the  limbs.  The 
cells  of  the  anterior  horn  in  the  thoracic  part  of  the  cord  are  rarely  dis- 
eased, this  causing  weakness  or  paralysis  in  the  abdominal,  lumbar,  and 
thoracic  muscles.  This  sometimes  produces  inability  to  sit  up  or  to  stand 
properly.  Following  the  loss  of  power  atrophy  develops,  the  degree 
depending  upon  the  extent  of  the  destruction  of  the  cells  in  the  anterior 
horn. 

The  tendon  reflexes  as  well  as  the  normal  electrical  reactions  will  be 
lost  in  those  parts  in  which  the  reflex  arcs  have  been  destroyed  or  inter- 
fered with. 

Not  only  will  there  be  atrophy  of  the  muscles,  but  there  will  also  be  an 
atrophy  of  the  bones  of  the  involved  limb.  Because  of  the  fact  that  the 
cells  in  the  anterior  horn  are  trophic  in  function,  there  will  also  be 
lessened  nutrition  of  the  skin  which  sometimes  becomes  dry  and  the  hair 
may  not  grow. 

It  is  not  at  all  uncommon  in  the  onset  of  the  disease  to  have  a  rigidity 
of  the  head,  neck,  and  limbs,  with  pain  in  the  back  and  neck  and  consider- 
able tenderness  in  the  limbs.  This  is  due  to  an  early  meningeal  involve- 
ment which  usually  does  not  last  very  long  and  subsides  within  two  or 
three  days  or  a  week.  In  rare  instances,  however,  the  pains  may  persist 
for  a  month  or  longer.  There  are  never  disturbances  of  sensation  or  of 
the  bladder  and  rectal  functions.  When  the  disease  appears  in  adults 
(rare)  the  onset  and  clinical  symptoms  do  not  differ  from  those  already 
described. 

Chronic  Poliomyelitis. — A  progressive  disease  of  the  spinal  cord,  charac- 
terized by  gradually  increasing  fibrillary  twitchings  beginning  in  the  hand, 
with  gradual  atrophy,  loss  of  power,  of  reflexes,  of  normal  electrical 
reactions  and  contractures  in  the  latter  end  of  the  disease  resulting  from 
chronic  degeneration  of  the  cells  of  the  anterior  horn  of  the  spinal  cord. 


198  DISEASES  OF  THE  NERVOUS  SYSTEM 

Syringomyelia. — A  chronic  disease  characterized  principally  by  typical 
dissociation  of  sensation,  that  is,  ability  to  recognize  touch  with  loss  or 
disturbance  of  pain  and  temperature  sensations,  combined  with  atrophy, 
fibrillary  tremors,  weakness  in  the  upper  and  sometimes  in  the  lower 
limbs,  with  spasticity  and  exaggerated  reflexes,  especially  in  the  lower 
limbs. 

The  syringomyelic  cavity  in  most  instances  results  from  lack  of  normal 
development  of  the  spinal  cord.  Sometimes  there  is  first  an  overgrowth 
of  neurogliar  tissue,  a  central  gliosis,  or  a  tumor  which  breaks  down, 
forming  a  cavity.  More  rarely  traumatism  may  produce  hemorrhages 
into  the  cord,  these  breaking  down  and  producing  cavities.  The  normal 
central  canal  may  be  widened,  producing  what  is  called  a  hydromyelia, 
but,  unless  it  is  very  large,  there  may  be  no  symptoms. 

Symptoms. — ^The  whole  symptom-complex  of  this  disease  depends 
upon  the  interruption  of  the  fibers  concerned  with  pain  and  temperature 
sensations  with  preservation  of  touch  sensation  and  the  involvement  of 
the  anterior  cornua  and  lateral  columns.  This  is  because  the  pain  and 
temperature  fibers  cross  over  in  the  central  gray  matter,  and,  as  the  cavity 
is  nearly  always  in  this  area,  these  functions  are  interrupted.  If  the 
cavity  is  limited  only  to  the  central  gray  matter  there  may  be  present 
only  the  dissociation  of  sensation  which  is  referred  to  the  related  periph- 
eral part,  usually  in  the  upper  limb,  but  in  most  cases  the  cavity  also 
involves  the  adjacent  cells  of  the  anterior  horns  plus  the  lateral  columns, 
their  related  symptoms  developing,  such  as  fibrillary  tremors,  atrophy, 
weakness,  with  spasticity  and  increased  reflexes  of  the  lower  limbs.  It 
can  be  readily  seen  then  that  the  symptoms  in  different  cases  may  vary. 

The  disease  usually  begins  in  a  young  adult,  the  patient  sometimes 
becoming  aware  of  it  by  the  fact  that  he  burns  himself  without  pain.  If 
examined,  touch  sensation  will  be  found  to  be  normal,  but  heat  or  cold 
or  both  will  not  be  recognized  as  such.  Sometimes  one  or  the  other 
temperature  sensation  alone  is  disturbed,  or  heat  may  be  referred  to  as 
cold  and  cold  as  heat.  The  disturbed  areas  are  usually  in  the  upper 
limbs,  chest,  and  back,  depending  upon  what  spinal  segments  are 
destroyed.  Coincident  with  this  dissociation,  or  soon  after,  atrophy, 
tremors,  and  weakness  in  the  small  muscles  of  the  hand  develop,  and  there 
may  be  present  a  typical  claw  hand,  its  progress  being  very  much  like 
that  of  either  progressive  muscular  atrophy  or  amyotrophic  lateral 
sclerosis.  Soon  after  there  may  develop  weakness  and  spasticity  of  the 
lower  limbs  with  exaggeration  of  the  tendon  reflexes  and  the  Babinski 
phenomenon. 

The  progress  of  the  disease  is  usually  slow  and  may  last  for  twenty  or 
thirty  years,  with  gradual  increase  of  the  wasting,  tremors,  and  loss  of 
power,  finally  involving  all  of  the  upper  limbs,  shoulders  and  chest, 
and  sometimes  the  lower  limbs.  The  areas  of  sensory  dissociation  also 
gradually  increase.  If  the  cavity  involves  the  gray  matter  of  the  lumbar 
and  the  sacral  cord,  besides  the  sensory  dissociation  in  the  lower  limbs 
and  buttocks  there  will  be  impairment  or  loss  of  bladder,  rectal,  and 
sexual  functions,  and  sometimes  there  may  be  loss  of  the  knee  and  Achilles 


DISEASES  OF  THE  SPINAL  CORD  197 

jerks,  because  of  interference  with  the  central  portions  of  the  reflex  arcs. 
If  the  cavity  extends  into  the  medulla  and  pons  the  symptoms  depend 
upon  the  extent  of  the  involvement.  Usually  in  the  medulla  the  cavity 
is  unilateral  and  there  may  be  partial  difficulty  in  eating,  talking,  and 
swallowing,  or,  if  bilateral,  typical  bulbar  symptoms  develop,  with  tremors, 
atrophy,  and  weakness  in  the  tongue,  facial,  masseter,  and  pterygoid 
muscles.  If  the  cavity  involves  the  sensory  fibers  there  may  be  dissoci- 
ation of  sensation  in  the  face.  Rarely  primary  optic  atrophy  occurs, 
and  more  rarely  still  pupillary  symptoms  because  of  involvement  of  the 
cervical  sympathetic. 

Trophic  symptoms  are  very  common  in  syringomyelia.  These  may 
consist  in  different  forms  of  skin  eruption  or  a  destruction  of  the  joints 
either  of  the  fingers  or  of  the  wrist  and  elbow  or  shoulder,  resembling 
very  much  the  so-called  Charcot  joint  of  tabes  dorsalis.  Occasionally 
there  may  be  sharp,  shooting  pains  in  the  limbs  and  girdle  sensation. 

Diseases  Involving  the  Motor,  or  Lateral,  Columns. — Lateral 
Sclerosis, — Gradual  weakness  in  the  lower  and  then  in  the  upper  limbs, 
spasticity,  increased  reflexes,  the  Babinski  phenomenon,  contractures  in 
the  latter  end  of  the  disease,  usually  with  the  thighs  adducted  and  flexed 
and  the  upper  limbs  in  flexor  contracture. 

Amyotrophic  Lateral  Sclerosis.— If  the  disease  involves  the  lateral  or 
motor  columns  plus  the  cells  of  the  anterior  horn,  there  will  be  weakness 
in  the  limbs,  spasticity,  increased  reflexes,  and  the  Babinski  phenomenon, 
plus  fibrillary  twitchings  and  gradual  atrophy.  Contractures  will  come 
on  in  the  latter  end  of  the  disease. 

Diseases  of  the  Posterior  Columns. —  Tabes  Dorsalis  (Locomotor 
Ataxia). — A  chronic  progressive  disease  characterized  first  by  numbness 
in  the  lower  limbs,  then  by  pains  of  a  sharp,  shooting  character,  girdle 
sensation,  difficulty  in  walking  and  in  execution  of  any  movement,  this 
being  especially  made  worse  with  the  eyes  shut;  absence  of  reflexes, 
disturbances  in  the  functions  of  the  bladder  and  rectum,  irregular  pupils, 
with  failure  of  the  reaction  to  light  and  later  optic  atrophy  and  dis- 
turbance of  sensation  in  various  portions  of  the  body. 

Syphilis  is  probably  the  most  important  cause  of  tabes  dorsalis, 
although  rarely  injuries,  especially  those  which  cause  pressure  or 
destruction  of  the  posterior  roots,  may  cause  identical  symptoms.  The 
pathology  consists  in  degeneration  of  the  posterior  roots,  with  con- 
sequent ascending  degeneration  of  the  posterior  sensory  columns.  There 
is  nearly  always  an  accompanying  meningitis,  especially  in  the  posterior 
part  of  the  cord. 

The  disease  is  slow  in  onset,  and  the  symptoms  come  on  gradually  over 
many  years.  There  is  nearly  always  first  numbness  in  the  lower  limbs 
and  sometimes  a  sensation  as  if  walking  on  leather  which  is  accom- 
panied or  followed  by  pains  of  a  sharp,  shooting  character,  usually  first 
described  as  rheumatic.  The  pains  are  not  limited  to  one  distribution, 
but  appear  at  irregular  places,  and,  as  the  disease  progresses,  may  be 
present  in  all  portions  of  the  body.  When  referred  to  the  viscera  they 
are  called  crises,  such  as  gastric,  intestinal,  urethral,  ocular,  etc.     Girdle 


198  DISEASES  OF  THE  NERVOUS  SYSTEM 

sensation,  or  a  feeling  of  tightness,  is  usually  manifested  around  the  abdo- 
men, but  may  be  present  elsewhere.  The  reflexes,  especially  the  patellar 
and  Achilles  jerks,  become  diminished  early,  and  later  are  lost  even  on 
reinforcement.  The  upper  arm  reflexes  also  become  gradually  lost. 
Inability  to  hold  the  urine,  constipation,  and  lessening  of  sexual  functions 
are  early  symptoms. 

Disturbances  in  sensation  are  prominent  and  can  usually  be  demon- 
strated early  and  involve  the  deeper  structures  more  than  the  superficial. 
It  is  characteristic  that  disturbances  of  touch  and  pain  are  nearly  always 
found  in  the  soles  of  the  feet  and  the  anterior  portion  of  the  legs  and  chest. 
The  alterations  in  sensation  are  gradual  and  in  association  there  is  always 
loss  of  muscular  sense,  so  that  the  patient  is  unaware  of  the  position  of 
his  toes,  feet,  or  limbs,  this  causing  disturbance  in  locomotion  and  ataxia, 
which  is  always  made  worse  when  the  eyes  are  closed.  The  disturbance 
in  the  gait  in  tabes  is  typical,  the  patient  nearly  always  walking  slowly 
with  the  head  bent,  usually  with  a  cane,  the  knees  are  bent  more  than 
they  should  be,  and  the  feet  placed  on  the  ground  forcibly.  If  the  patient 
should  shut  his  eyes,  he  would  stagger  and  sometimes  fall.  Coincident 
with  the  disturbance  of  sensation  and  muscle  sense  there  is  a  great 
amount  of  hypotonia,  this  being  manifested  by  the  abnormal  position  in 
which  the  limbs  can  be  placed. 

Among  the  early  symptoms  are  the  irregularity  of  the  pupil,  with  dimi- 
nution and  later  loss  of  the  iridic  reflexes  for  light,  but  with  motility  of 
the  iris  on  accommodation  for  distance,  the  so-called  Argyll-Robertson 
pupil.  Temporary  oculomotor  and  external  rectus  palsy  are  also  com- 
mon. Optic  nerve  atrophy,  involvement  of  the  fifth  nerve,  and  deafness 
are  occasional  complications.  Vasomotor  and  trophic  disturbances  are 
not  unusual,  and  consist  in  occasional  herpetic  eruptions,  disturbance  of 
sweat  secretions,  and  so-called  Charcot  joints  which  consist  in  an  altera- 
tion in  the  tissues  of  the  bones  and  in  the  articular  structures,  making 
it  possible  to  move  the  limbs  in  any  direction. 

Posterolateral  Sclerosis. — If  the  disease  involves  the  lateral  and  the 
posterior  columns  there  will  be  weakness,  spasticity,  increased  reflexes, 
and  the  Babinski  phenomenon  plus  disturbance  of  touch  sensation, 
ataxia,  and  involvement  of  bladder  and  rectum. 

Myelitis. — By  this  is  meant  inflammation  of  the  substance  of  the 
spinal  cord.  It  may  be  acute,  subacute,  or  chronic;  it  may  involve 
the  whole  diameter  of  the  spinal  cord  when  it  is  called  transverse,  or  it 
may  involve  parts  here  and  there  when  it  is  called  disseminated  mye- 
litis. It  may  be  the  result  of  syphilis  or  of  an  acute  infection,  or  the  result 
of  an  injury  (Fig.  71). 

Acute  Myelitis. — The  symptoms  of  acute  myelitis  depend  upon  the 
part  and  extent  of  the  spinal  cord  affected.  Usually  the  dorsal  region 
is  most  intensely  involved.  The  symptoms  may  come  on  rapidly,  some- 
times in  a  few  hours,  or  may  come  on  gradually  and  last  for  some 
weeks  or  months. 

When  the  result  of  an  injury,  the  symptoms  are  immediate.  There 
may  be  a  feeling  of  malaise  and  even  a  rise  of  temperature,  and  the 


DISEASES  OF  THE  SPINAL  CORD 


199 


patient  may  complain  of  a  feeling  of  numbness  or  of  a  tingling  sensation 
in  the  limbs,  sometimes,  also,  of  a  pain  in  the  back.  Following  this,  or 
perhaps  without  these  pains,  there  is  a  feeling  of  weakness  in  the  extrem- 
ities which  is  rapidly  followed  by  complete  flaccid  paralysis.  At  times 
a  total  paralysis  comes  on  within  a  few  hours.  Sensation  in  all  forms 
is  much  affected,  the  upper  limit  of  the  anesthesia  depending  upon  the 
location  of  the  lesion.  The  reflexes  may  be  lost  at  first,  but  in  a  short 
time  the  limbs  will  become  spastic,  the  reflexes,  such  as  the  patellar  and 
Achilles  jerks,  will  be  much  increased,  and  the  Babinski  phenomenon 
obtained.  The  vesical  and  rectal  sphincters  are  involved  from  the 
beginning,  there  being  at  first  retention  of  urine  and  constipation  fol- 
lowed by  incontinence.  Trophic  disturbances,  such  as  bedsores,  soon 
appear.  Wasting  of  muscles  and  the  reactions  of  degeneration  are 
obtained,  provided  the  cells  of  the  anterior  horns  supplying  these  parts 
are  destroyed. 

Fig.  71 


Contracture  of  the  lower  limbs  in  myelitis. 

If  the  affection  is  intense,  the  disease  extends  very  rapidly,  soon 
affecting  the  cells  supplying  the  respiratory  muscles  and  causing  death. 
If  the  patient  survives,  the  course  of  the  symptoms  will  depend  upon  the 
severity  of  the  lesion.  Usually  sensation  will  return  before  motion,  and 
the  patient  will  gradually  show  the  symptoms  of  spastic  paraplegia. 

Myelitis  Resulting  from  Injury. — The  symptoms  will  resemble  those 
already  described  with  the  exception  that  the  onset  is  sudden,  there  being 
no  premonitory  symptoms;  and,  as  the  destruction  of  the  cord  is  nearly 
always  intense,  the  picture  may  be  that  of  a  complete  transverse  myelitis, 
in  which  case  there  will  be  no  return  of  motion  and  sensation  in  the  parts 
below  the  point  of  injury. 

Serous  Meningitis. — Sometimes  all  of  the  symptoms  of  myelitis  may  be 
caused  by  pressure  due  to  an  increase  in  the  cerebrospinal  fluid,  the 
result  of  a  serous  meningitis.     It  is,  however,  impossible  to  recognize 


200  DISEASES  OF  THE  NERVOUS  SYSTEM 

this,  for  the  symptoms  are  identical.  Lumbar  puncture,  however, 
will  demonstrate  a  great  increase  in  the  quantity  of  fluid  and  a  heightened 
tension  in  the  spinal  canal. 

Diseases  of  the  Spinal  Roots. — Symptoms. — ^The  symptoms  will 
depend  upon  whether  the  anterior  or  the  posterior  roots  are  involved  and 
upon  the  extent  of  the  disease.  In  most  instances  it  is  impossible  to  tell 
whether  the  root  or  the  segment  of  the  spinal  cord  which  the  root  enters 
is  diseased,  and  it  is  important  to  remember  this  when  the  question  of 
surgical  procedure  is  considered,  for  it  will  then  be  necessary  to  expose 
not  only  the  spinal  segment  which  the  root  supplies,  but  the  whole  extent 
of  the  root  in  the  canal.  In  such  instances  it  is  advisable  always  to 
expose  first  the  exit  of  the  root  and  go  upward. 

In  the  differential  diagnosis  between  a  root  and  segment  lesion,  it  is 
noted  that  in  the  former  the  symptoms  are  more  liable  to  be  referred  to 
definite  parts.  In  the  latter  they  will  be  diffuse  and  involve  the  distri- 
bution of  other  roots,  for  a  lesion  of  the  cord  itself  is  hardly  ever  unilateral. 

Anterior  Root  Lesions. — As  the  anterior  roots  are  motor  there  will  be 
fine  tremors  or  twitchings  in  the  corresponding  muscle  fibers,  to  be  fol- 
lowed by  paralysis  when  the  root  is  destroyed.  If  the  lesion  extends 
farther  into  the  spinal  cord,  the  symptoms  of  this  will  be  apparent. 

Posterior  Root  Lesions. — These  are  more  common.  As  the  posterior 
roots  are  sensory  in  function,  any  lesion  will  first  give  irritative  phenomena, 
such  as  numbness  and  paresthesia  in  the  skin  distribution  related  to  these 
roots,  to  be  followed  by  pains  of  a  lancinating  character  or  girdle  sensation, 
and,  if  the  roots  are  destroyed,  anesthesia  in  the  related  parts.  There 
will  of  course  be  secondary  degeneration  in  the  columns  of  Goll  and 
Burdach. 

Unilateral  Spinal  Cord  Lesions,  or  Brown-Sequard  Paralysis. — 
Sometimes  tumors  or  injuries  resulting  from  bullet  or  stab  wounds  will 
cause  a  unilateral  lesion  of  one  or  two  segments  of  the  spinal  cord. 
The  symptoms  will  depend  upon  the  part  of  the  cord  involved  and  the 
extent  of  the  lesion.  Should  there  be,  for  instance,  a  unilateral  lesion  in 
the  eighth  cervical  and  first  thoracic  segments  of  the  right  side  of  the  cord, 
there  will  be  the  following  symptoms :  Because  of  the  destruction  of  the 
nerve  cells  in  the  anterior  horns,  inability  to  flex  or  extend  the  right  wrist 
or  move  the  fingers,  besides  atrophy  and  electrical  reactions  of  degen- 
eration in  these  parts.  Because  of  the  involvement  of  the  right  motor 
or  pyramidal  column,  weakness,  spasticity,  increased  reflexes,  and  the 
Babinski  phenomenon  in  the  right  lower  limb.  Because  of  the  destruc- 
tion of  the  sensory  roots,  loss  of  all  forms  of  sensation  along  the  under 
surface  of  the  whole  right  arm.  As  the  posterior  columns  transmit  the 
fibers  for  touch  sensation  and  muscle  sense  there  will  be  disturbance  of 
touch  in  the  right  lower  limb  and  right  abdomen  and  chest,  with  impair- 
ment of  muscle  sense  and  ataxia  in  the  right  leg.  In  the  left  lower  limb 
there  will  be  disturbance  of  pain  and  temperature  sensations  only, 
because  of  the  destruction  of  the  right  column  of  Gowers. 

Influence  of  Secondary  Degenerations. — ^Whenever  there  is  a  lesion  in 
any  portion  of  the  spinal  cord  there  will  necessarily  be  secondary  degenera- 


DISEASES  OF  THE  MENINGES  201 

tion.  If  the  motor  columns  are  involved,  the  degeneration  will  be  down- 
ward; if  the  sensory,  upward.  Secondary  degenerations  do  not  cause 
active  symptoms,  for  whatever  first  produced  the  original  lesion  has  also 
caused  the  secondary  degeneration,  and  this  is  no  more  than  a  mechanical 
death  of  the  part. 

DISEASES  OF  THE  MENINGES. 

The  meninges,  which  envelop  both  the  brain  and  spinal  cord,  are 
divided  into  the  outer  coat,  or  the  dura,  and  the  inner,  or  the  pia  and 
arachnoid.  Inflammation  of  the  dura  is  called  pachymeningitis,  and  of 
the  inner  coats  leptomeningitis.  With  the  exception  of  localized  inflam- 
mations and  those  following  injury,  inflammation  of  the  meninges  nearly 
always  involves  the  coverings  of  both  the  brain  and  spinal  cord. 

Cerebral  Pachymeningitis, — This  may  affect  either  the  outer  or  the  inner 
coat,  when  it  is  called  external  or  internal  pachymeningitis.  External 
'pachymeningitis  nearly  always  results  from  injury  to  the  skull,  and  is  not 
so  common  as  is  usually  thought.  It  may  be  secondary  to  a  growth  of 
the  overlying  bone,  especially  in  syphilitic,  tuberculous,  or  carcinomatous 
conditions. 

Internal  pachymeningitis  is  rare.  It  sometimes  is  hemorrhagic  in 
nature,  there  being  accumulations  of  blood  between  the  dura  and  pia, 
and  usually  occurs  in  old  persons,  especially  in  those  who  are  either 
arteriosclerotic  or  alcoholic.  It  is  rarely  found  in  some  forms  of  insanity. 
It  may  be  present  in  conjunction  with  external  pachymeningitis,  especially 
in  purulent,  syphilitic,  or  tuberculous  inflammation. 

Symptoms. — ^The  symptoms  of  pachymeningitis,  whether  external  or  in- 
ternal, are  indefinite  and  depend  upon  the  pressure  exerted  upon  the  brain. 
Generally  the  patient  complains  of  headache  and,  rarely,  of  tenderness 
localized  to  the  inflammatory  area,  the  specific  symptoms  depending 
upon  the  part  of  the  brain  involved.  If  in  the  motor  area,  there  will  be 
irritative  symptoms,  such  as  Jacksonian  convulsions,  which  may  be 
followed  by  greater  or  less  paralysis;  if  over  Broca's  convolution,  motor 
aphasia;  if  over  the  parietal  areas,  where  pachymeningitis  is  most 
common,  there  may  be  irritative  pains  or  paresthesia  on  the  other  side 
of  the  body,  accompanied  sometimes  by  disturbance  of  sensation;  if  over 
the  temporal  lobes,  aphasia;  if  over  the  occipital  convolutions,  disturbance 
of  vision  on  the  other  side.  There  may  sometimes  be  loss  of  conscious- 
ness, delirium,  or  stupor,  or  there  may  be  no  symptoms  at  all. 

Spinal  Pachymeningitis. — Isolated  inflammation  of  the  spinal  dura 
without  involvement  of  the  membranes  underneath  is  very  unusual  and 
hardly  ever  occurs.  In  some  instances,  however,  the  dura  is  preponder- 
antly involved.  As  a  rule,  inflammations  of  the  dura  are  secondary  to 
disease  of  the  vertebra,  as  in  tuberculous,  syphilitic,  carcinomatous,  or 
sarcomatous  lesions.  It  is  possible  to  have  a  syphilitic  pachymen- 
ingitis without  involvement  of  the  vertebra,  but  in  most  of  these  cases 
the  pia  and  spinal  cord  are  also  diseased.     The  symptoms  of  a  spinal 


202  DISEASES  OF  THE  NERVOUS  SYSTEM 

pachymeningitis  secondary  to  vertebral  inflammations  will  be  discussed 
under  the  latter  heading. 

Inflammation  of  the  Pia  Arachnoid. — Cerebrospinal  Meningitis. — 
In  most  cases  the  pia  of  the  brain  and  spinal  cord  are  involved  at  the  same 
time,  and  it  is  only  rarely  that  either  is  involved  alone.  Inflammations 
may  be  of  various  kinds.  The  other  varieties  are  purulent,  tuberculous, 
and  serous. 

Syphilitic  meningitis  has  been  discussed  under  the  head  of  Syphilis 
(p.  166). 

Purulent  Meningitis. — In  most  instances  purulent  inflammation  of  the 
meninges  is  secondary  to  septic  processes  elsewhere,  such  as  infected 
wounds  of  the  scalp  or  cranium,  sinusitis,  middle  ear  disease,  localized 
abscess  of  the  brain  or  pia,  and  general  pyemic  processes  or  ab- 
scesses in  the  various  parts  of  the  periphery;  or  secondary  to  a  septic 
endocarditis  or  one  of  the  infectious  diseases.,  as  pneumonia  or  typhoid. 
As  a  rule,  the  process  involves  equally  the  membranes  of  the  convexity, 
base  of  the  brain,  and  spinal  cord. 

Symptoms. — If  the  meningitis  occurs  in  the  course  of  an  infectious 
disease,  as  typhoid,  pneumonia,  septic  endocarditis,  or  is  secondary  to 
pyemic  processes,  injuries  to  the  head,  or  middle  ear  disease,  their  accom- 
panying symptoms  will  be  present,  and  very  often  the  early  symptoms  of 
meningitis  are  masked.  As  a  rule,  they  come  on  rapidly  with  headache, 
which  at  times  is  excessive,  and  a  rise  of  temperature,  the  patient  be- 
coming delirious,  stuporous,  and  then  unconscious.  The  pulse  generally 
at  first  is  rapid  and  then  slow  and  somewhat  irregular,  and  respiration 
becomes  more  or  less  embarrassed.  The  head  is  retracted,  the  back 
held  rigidly,  and  often  the  patient  assumes  a  position  of  opisthotonos. 
The  arms  are  retracted,  the  legs  are  flexed  on  the  abdomen,  and  any 
attempt  to  extend  the  legs  with  the  thighs  flexed  is  met  with  resistance 
(Kernig's  sign).  About  this  time  the  irritative  phenomena  become 
prominent,  and  there  may  be  general  convulsions,  or  the  spasms  may 
be  limited  to  one  or  more  limbs,  and  be  followed  by  partial  paralysis 
or  hemiplegia.  The  reflexes  may  be  exaggerated,  diminished,  or  lost. 
Because  of  basilar  involvement  the  pupils  become  irregular,  their 
reactions  impaired,  and  there  may  often  be  swelling  of  the  optic  nerve 
heads,  or  choked  disk.  Cranial  nerve  palsies  are  common,  especially 
of  the  sixth,  causing  diplopia;  the  third,  resulting  in  ptosis  of  the  upper 
lid  and  inability  to  move  the  eyeballs;  the  seventh,  paralysis  of  the  face; 
and  of  the  vagus,  interference  with  the  action  of  the  cardiac  and 
respiratory  functions,  and  ultimately  death.  Vasomotor  phenomena 
may  be  present  consisting  in  a  flushing  of  the  skin  after  stroking,  or 
tache  cerebrale. 

Tuberculous  Meningitis. — In  this  type  the  inflammation  is  nearly 
always  confined  to  the  membranes  of  the  base  of  the  brain,  although  there 
is  some  involvement  of  the  convexity.  In  nearly  all  cases  the  tuberculous 
meningitis  is  secondary  to  similar  processes  elsewhere,  especially  of  the 
lung,  intestines,  or  glands.  It  may  occur  in  adults,  but  in  most  instances 
it  affects  children  below  the  fifth  year. 


DISEASES  OF  THE  MENINGES  203 

Pathologically  there  is  found  tuberculous  inflammation,  with  small 
miliary  nodules,  and  there  is  nearly  always  some  serous  effusion. 

Symptoms. — When  occurring  in  an  adult,  there  are  nearly  always  the 
accompanying  symptoms  of  a  tuberculous  inflammation  elsewhere,  either 
in  lung,  pleura,  or  glands.  There  gradually  develops  headache,  irrita- 
bility, vomiting  and  nausea,  rigidity  of  the  head  and  neck,  some  disturb- 
ance of  consciousness,  and  then  the  symptoms  of  involvement  of  the 
cranial  nerves  at  the  base  of  the  brain.  These  are  choked  disk,  or  optic 
neuritis;  irregular  pupils,  with  disturbance  of  their  reactions;  ocular 
palsies,  drooping  of  the  upper  lid;  facial  paralysis;  disturbance  of  hearing 
and  of  cardiac  and  respiratory  functions.  Sometimes  there  may  be  con- 
vulsions or  paralysis  of  the  limbs  of  one  or  both  sides.  In  most  instances 
the  disease  is  fatal. 

Tuberculous  Meningitis  in  Infants. — When  it  occurs  in  infants  there  is 
usually  a  slow  onset  with  general  restlessness,  loss  of  weight,  rise  of 
temperature,  and  gastro-intestinal  disturbances  with  delirium,  uncon- 
sciousness, and  retraction  and  rigidity  of  the  head,  neck,  and  back, 
retraction  of  the  upper  and  lower  limbs,  and  the  symptoms  of  basal 
involvement  which  have  been  described  above.  Usually  the  disease 
terminates  in  death,  but,  if  the  patient  lives,  there  will  be  closure  of  some 
of  the  ventricular  connections  with  a  consequent  internal  hydrocephalus. 
Because  of  this  there  will  be  an  increase  in  the  size  of  the  head,  bulging 
of  the  fontanelles,  paralysis  of  one  or  both  sides  of  the  body,  impairment 
of  intellect,  and  a  general  rachitic  condition  of  the  body  with  its  accom- 
panying symptoms  of  maldevelopment. 

Serous  Meningitis^ — Meningism. — This  is  a  form  of  meningitis  only 
recently  described  in  which  there  is  an  effusion  into  the  meninges,  but 
in  which  there  is  no  exudation  such  as  occurs  in  the  purulent  variety. 

Under  the  teriameningis7n,7neningismus,  OTpseudomeningitis  has  been 
described  that  clinical  variety  in  which  the  symptoms  of  meningitis  are 
present,  but  in  which  pathologically  and  by  lumbar  puncture  nothing  is 
found  beyond  a  congestion  and  edema  of  the  vessels.  It  is  probable 
that  it  is  nothing  more  than  the  primary  stage  of  a  serous  meningitis. 
If  the  disease  goes  farther,  or  into  the  second  stage  of  effusion,  there  will 
be  what  is  commonly  termed  serous  meningitis. 

Meningeal  processes,  whether  of  an  irritative  or  of  an  effusive  nature, 
can  be  likened  to  similar  pathological  conditions  occurring  in  the  internal 
organs,  as  in  the  various  stages  of  a  pleurisy  or  pericarditis. 

Pathologically,  in  meningism  there  will  be  found  a  congestion  of  the 
bloodvessels  with  either  little  or  no  edema,  and  rarely  the  germ  of  the 
disease  may  be  found  in  the  meninges.  In  serous  meningitis  a  similar 
condition  is  present,  with  the  addition  that  there  will  be  a  serous  effusion 
with  an  increase  of  the  lymphocytic  elements,  and  only  rarely  will  a 
specific  organism  be  found. 

Sym^ptoms:  Meningism. — ^This  may  occur  in  the  course  of  or  follow 
any  infectious  disease,  such  as  pneumonia,  typhoid,  rheumatism,  scarlet 
fever,  measles,  or  la  grippe.  It  is  not  difficult  to  recognize,  for  there  will 
be  present  those  symptoms  which  are  commonly  termed  meningeal,  such 


204  DISEASES  OF  THE  NERVOUS  SYSTEM 

as  pain  along  the  back  or  limbs  which  may  be  of  a  numb  character  or 
may  be  decribed  as  sharp  and  shooting,  but  the  principal  complaint  is 
headache,  especially  in  the  back  of  the  head.  Besides,  there  will  be 
rigidity  of  the  head  and  back,  and  unwillingness  to  move  the  limbs  be- 
cause of  fear  of  increasing  the  pain.  Sometimes  there  will  also  be  hyper- 
esthetic  areas  in  different  parts  of  the  body.  There  may  rarely  be  mus- 
cular twitchings  in  the  limbs  and  a  general  increase  of  the  reflexes. 
Lumbar  puncture  is  negative.  The  onset  is  generally  acute.  The 
temperature  may  or  may  not  be  increased,  and  the  pulse  and  respiration 
are  not  much  altered.  The  duration  of  the  disease  is  usually  short  and 
the  prognosis  always  favorable.  Sometimes,  however,  there  may  be  a 
complicating  serous  effusion. 

Serous  Meningitis. — ^This  may  involve  either  the  brain  or  spinal  cord 
alone,  or  both.  There  will  be  in  addition  to  the  symptoms  enumerated 
above,  which  may  occur  first,  pressure  symptoms  resulting  from  the 
presence  of  fluid,  their  intensity  depending  upon  the  degree  of  the  pressure. 
When  the  spinal  cord  is  principally  involved,  there  will  be,  in  addition 
to  the  meningeal  symptoms,  pains  in  the  limbs,  girdle  sense  around 
the  waist,  and,  because  of  pressure  upon  the  anterior  and  posterior  roots 
and  later  on  the  spinal  cord,  disturbance  of  sensation,  increased  reflexes, 
which  are  later  lost,  and  bladder  and  rectal  disturbances.  Lumbar 
puncture  will  always  demonstrate  an  increase  in  the  intraspinal  pressure, 
and  there  will  be  considerable  exudation  of  fluid.  In  most  cases  the 
disease  lasts  only  a  few  weeks,  the  patient  getting  well. 

In  the  cerebrospinal  forms,  besides  the  symptoms  enumerated,  there 
will  be  some  disturbance  of  consciousness  and  greater  rigidity  of  the 
head  and  neck  and  of  the  limbs,  and  sometimes  a  swelling  of  the  optic 
nerve  heads.  More  rarely  there  may  be  temporary  diplopia  and  dis- 
turbances in  the  temperature,  pulse,  and  respiration.  Lumbar  punc- 
ture will,  of  course,  demonstrate  increased  intraspinal  pressure  with 
increase  of  fluid.  In  most  instances  the  symptoms  will  subside  in  a 
few  weeks,  the  patient  getting  well.  If,  however,  they  persist,  there  will 
develop  a  serous  effusion  in  the  cerebral  ventricles  with  its  accompany- 
ing symptoms  of  intraspinal  pressure. 

Cerebral  Serous  Meningitis. — A  serous  eft'usion  into  the  ventricles 
may  be  the  beginning  of  a  general  serous  meningitis,  or  may  be  confined 
only  to  them.  The  same  causes  which  are  active  in  the  production  of 
a  serous  meningitis  may  produce  an  internal  hydrocephalus. 

Pathologically  there  will  always  be  found  an  internal  and  sometimes 
also  an  external  hydrocephalus,  or  an  increase  of  fluid  in  the  cortical 
meninges.  Histologically  there  may  be  cloudy  swelling  and  prolifera- 
tion of  the  ependyma,  accumulation  of  cells  under  the  ependyma,  and 
cellular  infiltration  in  the  brain  and  spinal  cord  substance  and  in  its 
meninges,  especially  along  the  bloodvessels.  The  choroid  plexus  is 
nearly  always  diseased,  and  its  overaction  is  supposed  to  be  the  cause 
of  increase  in  fluid. 

Internal  hydrocephalus  resulting  from  serous  effusion,  as  a  rule,  comes 
on  in  early  childhood  and  is  not  difficult  to  recognize  if  the  process  is 


TUMORS  OF  THE  SPINAL  CORD  205 

active.  Very  often,  however,  there  may  be  only  mild  symptoms,  such  as 
have  been  described  under  meningism,  only  to  have  later  in  life  either  an 
acute  or  chronic  serous  meningitis  or  internal  hydrocephalus.  In  fact, 
many  writers  consider  that  serous  meningitis  or  serous  effusion  in  the 
ventricles  in  the  adult  is  only  an  acute  exacerbation  of  an  old  process 
which  had  its  origin  in  childhood.  However  that  may  be,  there  is  no 
question  that  in  the  adult  a  serous  effusion  may  develop  in  the  ventricles 
either  acutely  or  gradually  and  cause  symptoms  which  are  usually 
recognized  as  occurring  in  brain  tumor,  and  from  which  it  is  sometimes 
almost  impossible  to  make  a  differential  diagnosis. 

If  internal  hydrocephalus  develops  acutely  there  will  be,  as  a  rule,  an 
accompanying  high  fever  and  the  course  of  the  disease  will  be  rapid,  it 
resulting  either  in  cure  or  death.  Headache,  nausea,  vomiting,  vertigo, 
and  disturbance  in  vision  and  choked  disk,  sometimes  marked,  are 
prominent  symptoms.  Besides,  there  may  be  paralysis  of  some  of  the 
cranial  nerves,  especially  of  the  sixth,  either  on  one  or  both  sides,  and 
there  may  also  develop  cerebellar  ataxia.  Consciousness  is  nearly 
always  clouded.  The  disease  may  last  a  week  or  two,  terminating  in 
quick  recovery,  leaving  behind  slight  atrophy  of  the  optic  nerves,  but 
no  other  symptoms.  Sometimes  there  may  be  a  recurrence  of  the  disease, 
this  terminating  also  either  in  recovery  or  death.  The  diagnosis  from 
a  brain  tumor  can  usually  be  made  by  the  rapid  onset,  high  fever,  and  the 
quick  recovery  or  termination  in  death. 

If,  however,  the  symptoms  of  internal  hydrocephalus  come  on  gradually, 
the  differential  diagnosis  from  brain  tumor  will  be  very  difficult.  There 
will  be  present  all  the  pressure  symptoms,  such  as  headache,  nausea, 
vomiting,  vertigo,  and  choked  disk,  and,  because  of  the  pressure  exerted 
upon  the  motor  fibers  in  the  internal  capsule,  there  will  result  weakness 
and  spasticity  of  the  limbs  with  increased  reflexes  and  sometimes  the 
Babinski  reflex.  There  may  also  be  paralysis  of  the  external  rectus, 
either  on  one  or  both  sides.  Because  of  pressure  on  the  cerebellum  there 
will  result  incoordination  in  walking  and  sometimes  incoordination  of  the 
eyeballs,  or  nystagmus.  The  differential  diagnosis  from  cerebellar  lesions 
is  sometimes  very  difficult,  but  can  be  made  principally  upon  the  fact 
that  in  cerebellar  tumors  there  is  hardly  ever  involvement  of  the  limbs 
on  both  sides  and  the  ataxia  is  more  acute  and  much  more  marked. 

It  must  also  be  remembered  that  internal  hydrocephalus  may  also 
accompany  tumors  either  of  the  cerebrum  or  cerebellum,  and  in  such 
case  there  will  be,  in  addition  to  the  symptoms  resulting  from  the  tumor, 
spastic  paresis  of  the  limbs  with  increased  reflexes  and  the  Babinski 
phenomenon.  The  prognosis  in  most  cases  of  uncomplicated  internal 
hydrocephalus  is  not  very  good,  but  sometimes  complete  recovery  ensues 
either  as  a  result  of  operative  interference,  antisyphilitic  treatment,  or 
sometimes  spontaneously,  leaving  behind  nothing  but  a  slight  atrophy 
of  the  optic  nerves. 

Tumors  of  the  Spinal  Cord. — In  comparison  with  tumors  of  the  brain 
they  are  rare  and  may  be  extradural,  intradural,  or  involve  the  spinal 
cord   itself.     They  are   mostly  intradural,  tumors  of  the  cord  being 


206  DISEASES  OF  THE  NERVOUS  SYSTEM 

most  rare.  Pathologically  they  may  be  sarcoma,  fibroma,  glioma,  car- 
cinoma, or  cystic.  Tuberculous  and  such  other  tumors,  as  psammoma. 
myxoma,  endothelioma,  and  lipoma,  rarely  occur. 

Sarcoma .^ — Sarcoma  of  the  cord  itself  is  rare  and  is  secondary  to  that 
of  the  vertebra,  when  it  involves  the  anterior  and  especially  the  posterior 
roots  or  may  infiltrate  in  the  pia.  Generally  the  lower  portion  of  the. 
spinal  cord,  especially  the  cauda  equina,  is  the  seat  of  multiple  sar- 
comata. Their  characteristics  have  already  been  discussed,  and  it 
need  only  be  remembered  that  sarcomata  may  be  soft  and  infiltrating, 
and,  because  of  this,  may  give  only  a  few  symptoms. 

Fibroma. — These  tumors  are  mostly  intradural  and  grow  in  the  pia 
or  about  the  roots.  As  a  rule,  they  are  not  multiple,  and  are  favorable 
for  operative  removal. 

Cysts. — These  may  be  limited  to  the  meninges  and  be  simple  or  may 
be  multiple,  as  occurs  in  cysticercus  cellulosse  and  in  echinococcus  cysts. 

Symptoms. — These  will  depend  upon  the  location  of  the  tumor  and 
extent  of  the  involvement,  either  of  the  meninges,  root,  or  cord.  As  a  rule, 
most  tumors  are  located  in  the  thoracic  cord  and  are  generally  situated 
about  the  lateral  and  posterior  surfaces.  It  is  impossible  to  state  defi- 
nitely what  symptoms  may  occur  in  tumors,  but  they  are  either  due  to 
involvement  of  the  roots  or  the  spinal  cord  itself. 

Root  Symptoms. — Numbness  or  pain  or  girdle  sensation  to  be  followed 
by  pain  are  usually  among  the  first  manifestations,  these  being  referred 
to  the  parts  in  relation  with  the  posterior  root  diseased.  As  a  rule,  the 
pains  are  sharp,  shooting,  and  agonizing  in  character  and  may  be  of  such 
intensity  as  to  prevent  the  patient  from  moving.  If  the  growth  involves 
several  posterior  roots  and  is  large,  there  may  be  tenderness  and  pain  on 
pressure  over  the  involved  part,  and  jarring  may  sometimes  cause  excru- 
ciating pains.  Later,  there  may  be  an  accompanying  disturbance  of 
sensation. 

Cord  Symptoms. — As  the  spinal  cord  itself  becomes  involved  its  accom- 
panying symptoms  will  develop,  such  as  disturbance  of  sensation  if  the 
posterior  part  of  the  cord  is  affected,  and,  if  the  lateral  columns  are  com- 
pressed, there  will  be  weakness,  spasticity  with  increased  reflexes,  and  the 
Babinski  phenomenon  in  the  parts  below.  Of  course,  if  the  tumor  is 
around  the  anterior  part  of  the  cord  the  symptoms  will  be  purely  motor. 
This,  however,  is  uncommon. 

Tumors  of  the  Cauda  Equina. — These  are  generally  sarcomatous  and 
multiple.  The  symptoms  will  depend  upon  what  roots  are  involved. 
There  will  usually  be  pain  referred  to  the  sciatic  distribution  of  one  or 
both  sides,  or  possibly  a  localized  pain  in  the  lower  part  of  the  back,  but 
the  most  distinguishing  feature  is  the  segmental  disturbance  of  sensation 
around  the  buttock,  perineum,  anus,  and  in  the  genital  organs.  There 
may  also  be  disturbance  of  the  bladder,  rectal  and  sexual  functions. 
Paralysis  is  not  very  common,  but,  if  it  occurs,  will  usually  be  in  the 
distal  portions  of  the  limbs. 

Tumors  of  the  Vertebra. — These  are  generally  sarcoma  or  carcinoma, 
or  may  be  the  result  of  a  growth  of  the  bone  tissue,  when  they  are  called 


INJURIES  OF  THE  SPINAL  CORD 


207 


myelomata.  The  earlier  mentioned  tumors  are  nearly  always  secondary 
to  growths  elsewhere,  generally  from  the  lungs,  stomach,  breast,  prostate, 
or  uterus.  Such  benign  growths  as  osteoma  or  enchondroma  may  some- 
times occur. 

Root  and  Spinal  Cord  Symptoms. — As  the  disease  progresses  pressure 
will  be  first  exerted  on  the  posterior  roots,  and  the  first  symptoms  will  be 
those  of  numbness,  to  be  followed  by  sharp,  lancinating  pains,  with  girdle 
sensation,  referred  to  the  distribution  of  the  diseased  roots.  Any  jarring 
of  the  back  or  pressure  will  bring  on  a  fresh  attack  or  exaggeration  of 
pain.  As  the  disease  involves  the  dura  and  the  cord,  there  will  be  added 
disturbance  of  sensation  and  of  bladder  and  rectal  functions,  weakness 
in  the  limbs,  with  increased  reflexes,  spastic  condition,  and  the  Babinski 
phenomenon.  The  extent  of  the  paralysis  will  of  course  depend  upon 
the  amount  of  involvement,  there  sometimes  resulting  complete  myelitis 
and  total  paralysis  (Fig.  72). 

Fig.  72 


«*»■ 

■^  « 

i^                * "     *" 

rfjt  " 

ir*f 

SS^            *»/ii*'is)^SCi' 

\^ 

m 

m}^^ 

^b^^ ' 

'^        mkM| 

''k'' 

MBMEifaj>  >  3%. 

/jt^^ 

>^'  • . 

v^i"  V  ■'  ' 

wjUB^KBfjfi^     ^ 

^        -^fc  "BBK 

■f 

■■' V.fli!'&,'''''  •■''. " 

fSm^^^HBSMIl^    "^v 

^  (^i     «M  ^^3 

':*' 

.       „■?  •    : 

B^t.«raHii^ 

';'  ■  -^K  -'^^^^J^HBH 

^y  •'  -  j.iafcaH 

jM:-l-.-:y    ■■ 

"'^"''^•-■^"'■C'-^:^^|H 

iIlM 

u 

^^H 

^^^ 

'^K^Fj^ 

f=j2a 

-'4 

»  ?:    V 

H^^fl^^ 

^'^Sm 

m 

F/ 

%'*'■:. 

j^^^^^HUBfl^^^^^ 

i'^ 

'^'C^'jM 

■§ 

%d 

r:.>:.;-v-;.v 

|HBP^-|/^ 

1^ 

X*— ^ '  "  ■ 

iP^' 

Diffuse  myelitis  resulting  from  pressure  of  carcinomatous  tumor  of  the  vertebra. 


Injuries  of  the  Spinal  Cord. — The  result  of  any  injury,  no  matter 
how  trivial,  cannot  be  foretold.  There  may  be,  first,  a  sprain  or  injury  to 
the  ligaments  of  the  vertebral  column,  either  with  or  without  injury  of 
the  cord;  second,  fracture  or  dislocation  of  the  vertebra,  or  both,  either 
with  or  without  involvement  of  the  spinal  cord;  third,  injuries  to  the 
cord  itself;  and  lastly,  the  so-called  traumatic  neuroses  which  may 
enter  into  all  of  the  above  classifications  and  also  are  independent  of 
these.     The  symptoms  will  be  discussed  in  order. 

Sprain  or  Injury  to  the  Ligaments  of  the  Vertebral  Column,  with  or  without 
Involvement  of  the  Cord. — This  generally  results  from  overstretching 
of  the  vertebral  column  or  from  some  severe  muscular  effort.  A  direct 
injury  to  the  back  may  cause  a  contusion  of  the  ligaments.     As  a  rule, 


208 


DISEASES  OF  THE  NERVOUS  SYSTEM 


the  cord  itself  will  not  be  involved,  and  the  symptoms  will  be  those  of 
pain  localized  to  the  affected  parts,  with  accompanying  rigidity  of  the 
back  and  pain  on  movement.  There  should  be  no  difficulty  in  making 
this  diagnosis  were  it  not  for  the  fact  that  in  some  cases  there  may  be 
present  the  symptoms  of  a  traumatic  hysteria  which  may  resemble 
injury  of  the  cord,  or  there  may  be  what  not  infrequently  occurs,  multiple 
small  hemorrhages  or  areas  of  softening  in  various  portions  of  the  cord, 
and  sometimes  hemorrhages  into  the  substance.  Their  symptoms  will 
be  fully  discussed. 


Fig.  73 


Section  of  spinal  cord,  showing  diffuse  small  hemorrhages  and  one  large  hemorrhage  in  one 
posterior  horn  resulting  from  injury  to  the  spinal  cord.  The  section  is  taken  two  segments 
above  the  injury. 

Injuries  to  the  Cord. — In  nearly  all  cases  where  the  injury  has  been 
severe  enough  to  cause  a  fracture  or  dislocation  of  the  vertebra  the  cord 
itself  will  be  severely  damaged.  This  may  be  either  because  of  a  direct 
pressure  exerted  upon  the  cord,  the  result  of  forward  displacement  of 
the  vertebra,  or  as  sometimes  happens  there  will  be  at  the  time  of  injury 
a  sudden  torsion  or  twisting  of  the  spine,  this  causing  momentary  press- 
ure upon  the  cord,  with  destruction  of  its  elements.  Again,  there  may 
be  severe  injury  to  the  cord,  with  either  multiple  small  hemorrhages  or 
softening  or  one  large  hemorrhage,  but  no  evidence  of  fracture  or  dislo- 
cation or  even  sprain  or  contusion  of  the  ligaments  (Fig.  73). 

The  symptoms  of  compression  of  the  cord  will  not  differ  from  those 
described  under  the  head  of  myelitis.  As  a  rule,  the  destruction  will  be 
intense,  and  transverse  myelitis  and  sometimes  complete  severance  of 
the  cord  will  result,  this  causing  complete  loss  of  power  and  of  sensation 
in  the  parts  below,  with  bladder,  rectal,  and  trophic  symptoms.     It  must 


INJURIES  OF  THE  SPINAL  CORD 


209 


also  be  remembered  that  besides  the  direct  destruction  of  the  cord,  the 
result  of  the  injury,  there  will  also  be  multiple  small  areas  of  hemorrhage 
above  and  below  the  point  of  injury.  If  there  is  only  a  partial  destruc- 
tion, there  will  be,  after  the  initial  complete  paralysis  of  motion  and  sensa- 
tion, return  of  sensation,  and  then  of  motion,  with  increased  reflexes,  spas- 


FiG.  74 


Pliotograph  showing  complete  bilateral   foot  drop  with,  contracture  and  trophic  changes   in 
case  of  myelitis  resulting  from  injury  to  the  cord. 


Fig.  75 


Backward  dislocation  of    fifth   cervical  vertebra  resulting  from  a  fall,  causing  pressure  upon 
the  spinal  cord,  with  partial  paralysis  of  the  upper  limbs  and  to  a  less  extent  of  the  lower. 

ticity,  Babinski  phenomenon,  and  disturbance  of  bladder  and  rectal 
functions. 

Hemorrhages  into  the  cord,  or  hematomyelia,  may  occur  with  contusion 
of  the  substance  of  the  cord  or  independently  of  this  as  a  result  of  injuries 
14 


210 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Fig.  76 


without  an  accompanying  fracture  or  dislocation  of  the  vertebra.  As  a 
rule,  hemorrhages  occur  into  the  substance  of  the  cord  mostly  in  the 
central  gray  matter,  and  only  very  rarely  in  the  outer  or  inner  surface 
of  the  dura.  The  gray  matter  of  the  cord  seems  to  be  easier  to  infiltrate 
than  the  white  matter,  and  as  a  consequence  any  hemorrhage  may 
involve  considerable  length  of  the  cord.  The  symptoms  will  depend 
largely  upon  the  location  of  the  lesion,  whether  within  the  cervical, 
thoracic,  or  lumbar  parts,  and  upon  its  extent.  As  the  hemorrhage 
involves  principally  the  middle  portion  of  the  cord,  it  will  interrupt  the 

fibers  concerned  with  transmission  of 
pain  and  temperature  sensations,  and 
there  will  result  the  so-called  syringo- 
myelic disturbance  of  sensation  in  the 
loAver  limbs,  i.  e.,  loss  of  pain  and  tem- 
perature sensations  with  preservation 
of  touch.  Besides,  there  will  be  weak- 
ness with  spasticity,  increased  reflexes, 
and  the  Babinski  phenomenon,  and,  if 
the  hemorrhage  involves  the  cells  of 
the  anterior  horn,  loss  of  power  with 
atrophy  and  reaction  of  degeneration 
in  the  related  parts. 

If,  however,  there  should  be  multiple 
microscopic  areas  of  hemorrhage  or 
softening,  no  definite  symptoms  will 
result,  because  there  has  not  been  suffi- 
cient injury  to  cause  disturbance  in 
function  unless  the  injury  occurs  where 
marked  arteriosclerosis  is  present,  when 
severe  hemorrhages  or  softening  may 
be  brought  on  any  time  through  the 
weakening  of  the  vessel  walls  (Fig.  74). 
The  Prognosis  of  Injuries  of  the 
Spinal  Cord. — ^This  will  depend  upon 
the  nature  and  the  extent  of  the 
injury.  If  the  cord  has  been 
severely  crushed  for  several  seg- 
ments, there  can  be  no  hope  for 
return  of  function.  If  the  injury  has  been  partial,  some  return  of  power 
will  always  result.  If  a  hemorrhage  has  occurred  in  the  central  gray 
matter,  there,  should  be  some  return  of  power,  and  if  multiple  microscopic 
areas  of  hemorrhage  or  softening,  complete  recovery  may  ensue.  In 
all  these  instances  the  prognosis  depends  entirely  upon  the  possible 
regeneration  of  fibers  in  the  spinal  cord,  and  this  has  been  the  subject  of 
controversy  for  a  long  time.  It  is  probable  that  this  cannot  occur, 
and  improvement  results  because  the  fibers  which  have  been  injured 
have  recovered  from  whatever  traumatism  they  had  been  subjected 
to.     In  every  injury  there  is  a  certain  amount  of  shock  which  will  tem- 


Partial  dislocation  of  the  second  and 
third  cervical  vertebra  due  to  injury, 
showing  attitude  and  rigidity  of  the  head 
and  neck. 


TRAUMATIC  NEUROSES  211 

porarily  injure  the  cord  but,  unless  a  complete  severance  or  myelitis 
ensued,  there  should  nearly  always  be  some  return  of  function. 

Spina  Bifida. — A  defect  in  the  closure  of  the  posterior  vertebral  arches, 
especially  in  the  lumbar  and  the  sacral  region.  It  is  of  embryonal  origin 
and  is  usually  detected  at  birth  or  very  soon  after,  and,  rarely,  may  inter- 
fere with  it.  The  defect  may  consist  only  in  a  lack  of  union  of  the  posterior 
vertebral  arches,  but,  as  a  rule,  there  is  a  tumor-like  projection  in  the 
lower  spine  which  may  consist  only  in  a  protrusion  of  the  dura,  and  which 
may  be  from  the  size  of  a  nut  to  that  of  an  orange  or  larger  and  be  filled 
with  cerebrospinal  fluid;  or  there  may  be  in  connection  with  the  dural 
protrusion  an  involvement  of  the  spinal  cord  itself,  consisting  either  in 
an  enlargement  of  the  central  canal,  a  hydromyelia,  or  attachment  of  the 
lumbosacral  cord  or  its  roots  to  the  walls  of  the  sac. 

Symptoms. — Most  cases  of  spina  bifida  die  either  at  or  soon  after  birth. 
When  there  is  only  a  dural  involvement,  there  may  be  no  symptoms 
except  the  physical  evidences  of  the  protrusion.  Pressure,  however, 
upon  the  sac  will  cause  bulging  of  the  fontanelles  with  the  symptoms  of 
cerebral  compression.  If,  however,  the  cord  itself  be  involved,  there  will 
be  paralysis  of  both  lower  limbs  and  disturbance  of  bladder  and  rectal 
functions  and  of  sensation.  The  disease  is  of  long  duration,  the  symp- 
toms having  a  tendency  to  increase,  and  the  prognosis  is  not  very  good. 
There  are  frequently  in  association  embryonal  defects  elsewhere,  such  as 
cleft  palate  or  harelip. 

Traumatic  Neuroses. — Under  this  head  will  be  discussed  the  so- 
called  traumatic  neurasthenia,  hysteria,  and  hysteroneurasthenia  which 
occur  as  the  result  of  injuries  to  any  part  of  the  body,  especially  to  the 
head  and  back.  No  matter  how  trivial  the  injury  or  what  part  of  the 
body  has  been  injured,  there  may  be  a  certain  amount  of  accompany- 
ing shock,  and,  even  in  those  cases  where  the  injury  has  produced 
unconsciousness  this  may  occur  afterward.  It  can  be  seen,  then,  that 
in  every  case  of  injury  there  may  be  a  certain  amount  of  so-called 
neurasthenia  or  hysteria,  and  the  repeated  examinations  by  physicians 
and  the  constant  attention  paid  to  the  patient  during  the  process  of 
litigation  may  tend  to  increase  and  cause  new  symptoms.  It  is 
important  from  the  standpoint  of  the  patient  to  settle  the  case  as  soon 
as  possible. 

Traumatic  Neurasthenia. — ^This  is  generally  produced  by  injury  to  the 
back  or  head,  or  may  follow  injuries  to  other  portions  of  the  body.  It 
may  also  be  due  to  such  other  causes  as  fright,  the  result  of  lightning 
and  other  physical  or  mental  shock.  It  must  be  remembered  that  the 
symptoms  of  neurasthenia  may  be  entirely  in  disproportion  to  the  extent 
of  the  injury,  for  sometimes  the  most  trivial  cause  may  produce  the 
greatest  number  of  symptoms,  and  vice  versa.  The  symptoms  of  trau- 
matic neurasthenia  do  not  differ  from  those  the  result  of  other  conditions. 
They  are  subdivided  into  mental,  sensory,  motor,  and  special. 

Mental  Symptoms. — ^The  patient  at  the  time  of  the  injury  may  not 
have  any  mental  shock,  may  be  badly  frightened,  or  be  unconscious. 
Very  often  the  patient  who  does  not  suffer  the  slightest  perturbance  at 


212  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  time  of  the  accident  may  become  the  worst  neurasthenic,  and  in 
nearly  all  cases  the  impression  of  the  accident  will  remain  for  some  time 
and  will  be  the  dominant  topic  of  thought  and  conversation.  To  this 
may  be  added  the  fear  of  having  sustained  a  severe  and  irreparable  injury. 
In  a  short  time  the  patient  will  be  chiefly  or  entirely  occupied  in  thinking 
of  his  accident  and  of  his  symptoms  to  the  exclusion  of  every  other  topic. 
Because  of  this  he  will  complain  of  loss  of  memory,  of  inability  to  attend 
to  details  of  business,  and  insomnia,  but  the  greatest  trouble  will  be  that 
every  little  symptom  will  be  exaggerated.  This  mental  condition  may 
last  for  some  time,  especially  if  litigation  is  prolonged,  but  under  proper 
care  most  cases  should  get  well. 

Sensory  Symptoms. — Pain  along  the  back  is  one  of  the  commonest 
symptoms,  especially  if  the  spine  has  been  injured.  It  is  generally 
described  as  dull  and  aching,  and  sometimes  it  is  located  in  the  lower 
portion  of  the  back,  when  it  will  have  the  characteristics  of  lumbago. 
Any  pressure  over  the  painful  spots  or  bending  of  the  body  will  increase 
the  pain. 

Headache  is  very  frequent  and  is  generally  in  the  back  of  the  head 
and  neck,  and  sometimes  radiates  into  the  frontal  region.  It  is  usually 
described  as  dull  and  aching  with  occasional  exaggerations.  Sometimes 
the  patient  will  complain  of  pains  of  a  numb  character  in  the  limbs,  and 
often  this  is  accompanied  by  pain  on  pressure  over  all  parts  of  the  body. 

Motor  Symptoms. — Physical  weakness  is  one  of  the  commonest  and 
most  constant  manifestations  of  neurasthenia,  the  patient  complaining 
of  exhaustion  and  of  inability  to  perform  repeated  muscular  efforts.  On 
testing  such  a  patient  it  will  be  found  that  the  grip  or  resistance  against 
movement  may  be  strong  at  first,  but  that  the  patient  is  easily  exhausted. 
The  reflexes  will  generally  be  increased,  and  very  often  there  may  be 
irregular  tremors  all  over  the  body  of  a  fibrillary  or  of  a  coarser  character. 

Special  Symptoms. — Pain  in  the  eyeballs  with  dimness  of  vision  and 
inability  to  read  for  any  length  of  time  is  a  very  common  symptom,  as 
is  also  some  diminution  in  hearing.  Loss  of  appetite,  nausea,  vomiting, 
and  constipation  are  also  very  frequent. 

Traumatic  Hysteria. — ^The  same  causes  which  are  productive  of  neu- 
rasthenia will  also  produce  hysteria.  While  neurasthenia  is  considered 
as  being  due  to  an  alteration  of  function  produced  by  fatigue  or  exhaus- 
tion, hysteria  is  probably  more  the  result  of  a  cerebral  disturbance  because 
the  symptoms  of  it  are  such  as  may  result  from  cerebral  lesions.  It  is 
probable  that  the  two  conditions  are  identical,  and  that  in  hysteria  we 
have  the  severest  form  of  the  affection.  The  symptoms  may  be  sub- 
divided similarly  to  those  of  neurasthenia. 

Mental  Symptoms. — What  has  been  said  of  the  mental  symptoms 
occurring  in  traumatic  neurasthenia  will  also  answer  for  those  of  trau- 
matic hysteria,  only  in  hysteria  the  patient  is  much  more  impressionable 
and  the  symptoms  are  generally  more  marked  and  numerous. 

Sensory  Symptoms. — Here,  as  in  neurasthenia,  backache  and  headache 
and  difTuse  pains  in  all  parts  of  the  body  ^re  very  common.  It  is  not 
unusual  to  find  that  the  patient  has  diminution  or  loss  of  sensation  for 


TRAUMATIC  NEUROSES  213 

touch,  pain,  and  temperature  over  a  part  of  a  limb,  a  whole  limb,  or  one- 
half  of  the  body,  and  sometimes  of  all  parts  of  the  body. 

Instead  of  diminution  of  sensation  there  may  be  a  hyperesthesia.  This 
is  generally  over  certain  spots,  as  over  the  back  of  the  head,  neck,  and 
spine,  and  in  the  inframammary,  ovarian,  and  inguinal  regions  and  some- 
times over  the  limbs. 

Motor  Symptoms. — Here,  as  in  neurasthenia,  the  dominant  symptom 
will  be  that  of  fatigue  and  easy  exhaustion  with  muscular  tremors  and 
increase  of  the  tendon  and  skin  reflexes.  Besides,  there  may  be  paralysis, 
which  may  involve  a  part  of  a  limb,  a  whole  limb,  or  a  half  of  the  body, 
giving  the  symptoms  of  a  monoplegia,  a  hemiplegia,  and  more  commonly 
still  there  may  be  a  paralysis  of  both  lower  limbs  simulating  paraplegia. 
It  is  important  to  diagnosticate  these  from  organic  lesions.  We  may  have 
in  hysteria  the  usual  mental  and  sensory  symptoms,  but  it  must  be 
recalled  that  these  may  also  accompany  an  organic  lesion;  the  differen- 
tial diagnosis  must  be  made  upon  the  onset,  character,  and  symptoms  of 
the  paralysis.  It  will  be  found  that  the  onset  is  more  or  less  sudden  and 
not  commensurate  with  the  extent  of  the  injury,  that  the  paralysis  is  not 
complete,  and  that  when  the  patient  is  taken  off  guard  considerable 
power  may  be  manifested.  Again,  while  there  always  will  be  a  general 
increase  of  tendon  reflexes  and  sometimes  an  ankle  clonus,  the  Babinski 
reflex  never  occurs  in  hysteria.  Besides,  the  patient  is  always  amenable 
to  suggestion,  and  even  an  increase  in  the  paralysis  may  be  brought  about. 

Contractures  may  sometimes  result  in  a  limb,  either  accompanying  an 
hysterical  paralysis  or  without  this.  The  contractures  are  usually  not 
of  the  regular  type,  and,  if  general  anesthesia  is  induced,  complete  flac- 
cidity  will  result. 

Tremors  are  not  unusual  and  occur  in  various  portions  of  the  body 
or  only  in  one  limb,  when  they  may  be  of  the  most  violent  character  and 
usually  out  of  proportion  to  the  injury,  and  are  accompanied  by  the  usual 
hysterical  symptoms.  Sometimes  convulsions  may  result.  These  may 
be  partial  or  general  and  may  resemble  closely  an  epileptic  attack.  A 
differential  diagnosis,  however,  can  always  readily  be  made  by  the  fact 
that  in  hysteria  there  will  not  be  the  history  of  attacks  occurring  in  child- 
hood, there  will  be  no  aura  or  preliminary  cry,  the  patient  will  never  hurt 
himself,  and  there  will  be  no  biting  of  the  tongue  or  voiding  of  urine. 
Besides,  the  movements  will  not  have  the  regular  clonic-tonic  succession, 
they  being  mostly  wild  and  irregular,  and  most  important  of  all,  uncon- 
sciousness will  not  result.  Attacks  may  be  brought  about  by  any  emo- 
tion, and  are  generally  prolonged  for  a  number  of  minutes  and  sometimes 
for  hours. 

Special  Symptoms. — Pain  in  the  eyeballs  and  visual  irritability  and 
fatigue  when  reading  are  very  common  symptoms.  Sometimes  to  this  are 
added  such  irritative  phenomena  as  flashes  of  light  and  spots  of  various 
kinds  which  appear  in  the  field  of  vision.  In  grave  cases  there  may  be 
diminution  in  the  fields  of  vision  of  one  or  both  eyes  which  may  or  may 
not  be  homonymous,  and  at  times  there  may  be  complete  hemianopsia 
and  reversion  of  the  color  fields. 


214  DISEASES  OF  THE  NERVOUS  SYSTEM 

Diminution,  loss  or  hyperacuity  of  hearing  sometimes  occurs.  There 
may  also  be  perversion  in  taste  and  smell  or  loss  of  these  senses.  Dis- 
turbances in  gastric,  bladder,  and  rectal  functions  are  not  infrequent 
symptoms. 

Traumatic  Hysteroneurasthenia. — In  the  majority  of  cases  the  symp- 
toms both  of  hysteria  and  neurasthenia  occur,  and  only  very  rarely  do  we 
have  either  condition  alone.  It  will  not  be  necessary  to  give  the  symp- 
toms of  hysteroneurasthenia,  as  these  have  already  been  sufficiently 
discussed. 

DISEASES  OF  THE  PERIPHERAL  NERVES. 

Only  those  nerves  which  are  commonly  injured  or  diseased  will  be 
considered.  Any  motor  or  sensory  nerve  may  be  inflamed,  constituting 
neuritis.  By  neuralgia  is  meant  an  inflammation  of  a  sensory  nerve 
only,  whether  this  be  peripheral  or  cranial.  There  are  many  causes 
for  neuritis  and  neuralgia,  many  of  these  being  constitutional  disturb- 
ances, local  causes,  contusions,  and  injuries;  but  a  large  number  of 
diseases  of  the  nerves  come  on  apparently  without  any  cause,  at  least 
no  cause  can  be  found  by  the  microscope,  and  are  thought  to  be  func- 
tional in  origin. 

Every  peripheral  nerve  consists  of  an  axis  cylinder,  of  an  enveloping 
substance  called  myelin,  and  of  a  sheath  which  surrounds  the  myelin 
substance  called  the  neurilemma.  The  nerves  in  the  brain  and  spinal 
cord  do  not  have  this  sheath,  and  those  of  the  sympathetic  system 
also  do  not  contain  it  nor  are  they  surrounded  by  myelin  substance. 
Regeneration  will  occur  in  every  peripheral  nerve. 

Inasmuch  as  the  function  of  every  peripheral  and  cranial  nerve  is 
concerned  either  with  motion,  sensation,  or  with  both,  the  symptoms  must 
depend  upon  what  nerve  is  diseased.  If  a  motor  nerve,  there  will  be 
paralysis;  if  sensory,  disturbance  of  sensation,  this  being  manifested  by 
numbness,  a  tingling  feeling,  or  pin  and  needle  sensation,  or  by  pain,  and, 
if  the  nerve  is  destroyed,  by  anesthesia.  As  most  nerves  are  both  motor 
and  sensory  there  will  be  both  paralysis  and  disturbance  of  sensation. 
There  will,  besides,  be  such  trophic  phenomena  as  disturbance  in  skin 
secretions,  with  either  excess  or  absence  of  sweating,  drying  of  the  skin 
and  nails,  and  falling  out  of  the  hair.  If  a  motor  nerve  is  diseased 
there  will  also  be  electrical  reactions  of  degeneration  and  loss  of  reflexes. 

Reactions  of  Degeneration: — A  normal  nerve  or  muscle  will  respond  to 
any  form  of  electrical  stimulation.  If  it  is  diseased,  it  will  not  respond 
to  a  faradic  current,  but  will  give  an  increased  and  prompt  response  to  a 
galvanic  current,  and  the  reaction  obtained  will  be  slow  and  sinuous  in 
contrast  to  the  quick  and  prompt  response  obtained  when  a  nerve  is 
normal.  The  usual  method  of  testing  is  to  apply  first  a  slowly  interrupted 
faradic  current  to  the  corresponding  normal  nerve,  and  then  try  the  same 
current  on  the  diseased  nerve.  If  a  nerve  is  completely  diseased  or 
severed,  no  reaction  will  be  obtained  to  the  faradic  current.  The  galvanic 
current  is  then  tried,  and  a  minimum  current  applied  to  the  diseased 


PLATE    IX 


s/* 


Inf.  Heemorrkoidal 
of  Pudic 

Superficial  Perineal  ofV 
Pudic  and  Inferior    I 
Pudendal  of  small     ( 
jSciatic  ^ 


'Ti\     ft 


V- 


■ofS,n„l/g 


The  Distribution  of  Sensory  Nerves  in  the  Skin.      (After  Flower.) 

The  areas  of  the  skin  supplied  by  the  cutaneous  nerves  are  shown  in  finely  dotted 
outline.  The  circles  on  the  trunk  show  areas  occasionally  ansesthetic  in  hysteria.  The 
lines  across  the  limbs  at  ankle,  knee  and  thigh,  wrist,  elbow  and  shoulder  show  the  upper 
limits  of  anesthesia  in  multiple  neuritis  of  varying  degrees  of  severity. 


DISEASES  OF  THE  PERIPHERAL  NERVES  215 

nerve  first,  when  the  response  will  be  slow  and  sinuous.  The  same  current 
applied  to  the  healthy  nerve  will  not  cause  any  reaction,  and  to  obtain  a 
response  it  will  be  necessary  to  increase  the  current  to  such  an  extent 
that  it  will  be  painful.  Reactions  of  degeneration  are  not  obtained  until 
about  one  or  two  weeks  after  the  severance  of  the  nerve,  and  tests  for 
them  should  never  be  made  as  long  as  a  nerve  is  inflamed  or  there  is  pain 
on  pressure.    The  presence  of  these  reactions  makes  the  prognosis  grave. 

Diseases  of  the  Cranial  Nerves. — Tic  Douloureux. — Painful  paroxysms 
of  the  fifth  nerve  are  due  to  many  causes,  but  in  the  majority  of  instances 
no  ascertainable  factor  can  be  found.  Repeated  examinations  of  the 
Gasserian  ganglia  have  demonstrated  occasionally  diseases  of  the  nerve 
cells,  but  this  is  not  constant  and  the  real  cause  is  not  known.  Rarely 
eyestrain,  antrum  disease,  or  dental  irritation  may  cause  pains  in  part 
of  the  distribution  of  the  fifth  nerve,  but  in  a  well-marked  case  of  tic 
douloureux  the  cause  is  nearly  always  undefined.  The  disease  may 
involve  at  first  or  be  always  limited  to  one  branch  of  the  fifth  nerve, 
usually  to  the  supra-orbital,  when  it  is  termed  supra-orbital  neuralgia.  As 
a  rule,  it  begins  with  an  occasional  numbness  in  one  of  the  divisions,  this 
becoming  more  frequent  and  severe,  the  onset  of  the  disease  lasting 
sometimes  over  a  number  of  years,  to  be  followed  by  pain  which  involves 
two  and  lastly  all  the  branches.  If  the  disease  is  limited  to  the  supra- 
orbital nerve,  pain  will  be  marked  over  the  forehead  and  brow  and  there 
will  be  pain  in  the  eye  and  sometimes  a  sensation  of  a  foreign  body. 
Occasionally  the  pains  will  be  so  sharp  as  to  cause  closure  of  the  eye  with 
flow  of  tears.  Inflammation  limited  to  the  middle  or  infra-orbital  nerve, 
infra-orbital  neuralgia,  will  cause  numbness  or  pain  in  the  upper  jaw, 
palate,  and  upper  teeth,  and  sometimes  in  the  tongue.  If  the  disease 
is  limited  to  the  inferior  branch,  the  pain  will  be  in  the  lower  jaw,  teeth, 
and  tongue,  it  being  aggravated  by  eating  or  talking.  There  will, 
besides,  be  pain  on  pressure  over  the  nerves  at  their  exits.  If  the  disease 
involves  all  parts  of  the  fifth  nerve,  the  pain  will  come  on  spasmodically 
and  cause  the  most  excruciating  pains  over  the  whole  side  of  the  face,  and 
contractions  or  spasms  of  the  muscles.  Accompanying  this  there  may 
be  flow  of  tears  and  pain  on  pressure  over  the  exits  of  the  nerve.  At  such 
times  any  irritation,  no  matter  how  slight,  as  talking  or  eating,  will  bring 
on  a  fresh  attack,  and  there  may  also  be  hyperesthesia  in  the  distribution 
of  the  trigeminus. 

The  prognosis  in  a  well-marked  case  is  poor,  inasmuch  as  operative 
procedure  ofl^ers  the  only  relief.  In  such  case,  whether  the  Gasserian 
ganglion  be  excised  or  the  sensory  root  cut,  relief  of  pain  will  be  obtained 
and  there  will  be  anesthesia  in  the  distribution  of  the  fifth  nerve.  It  is 
important  to  remember  that  while  superficial  sensation  or  the  sensation 
for  touch,  pain,  and  temperature  is  lost,  deep  sensibility  is  retained, 
because  of  the  fact  that  this  sense  is  transmitted  by  the  deep  or  muscular 
nerves,  and  not  by  the  fifth  nerve.  It  is  because  of  this  that  very  often 
a  mistake  is  made  in  believing  that  the  fifth  nerve  has  not  been  cut,  when, 
as  a  matter  of  fact,  careful  test  will  demonstrate  that  superficial  sensa- 
tion is  lost,  and  it  is  only  deep  pressure  that  is  appreciated. 


216 


DISEASES  OF  THE  NERVOUS  SYSTEM 


Fig.  77 


Facial  Tic  and  Spasm. — Until  recently  no  differentiation  was  made 
between  spasm  and  tic.  By  tic  is  meant  a  movement  or  movements 
which  are  more  or  less  under  the  control  of  the  will  and  result  from  some 
emotional  or  functional  cause,  duplicating  or  resembling  voluntary 
movements.  In  whatever  part  tic  takes  place  the  muscular  action  is 
complete,  as,  for  instance,  in  facial  tic  the  contraction  is  in  the  whole  facial 

distribution,  its  occurrence  not 
interfering  with  the  use  of  the 
same  musculature  for  other  pur- 
poses, as  eating  and  talking.  The 
movements  are  quick,  intermit- 
tent, have  a  tendency  to  become 
chronic,  and  cease  during  sleep. 
On  the  contrary,  by  spasm  is 
meant  a  movement  which  is  not 
at  all  under  the  control  of  the 
will,  and  which  cannot  be  volun- 
tarily duplicated.  Contraction 
usually  involves,  at  first,  part, 
and  later  all,  of  a  functionally 
acting  group  of  muscles,  and  in- 
terferes with  their  use,  as,  for  in- 
stance, in  facial  spasm,  the  con- 
traction may  be  limited  first  to  a 
part  and  later  involve  all  the  facial 
distribution.  The  movement  does 
not  resemble  a  voluntary  action 
and  interferes  with  eating  and 
talking. 

The  causes  of  spasms  and  tics 
are  not  known,  but  it  is  prob- 
able that  they  are  functional  in 
origin.  Rarely  a  spasm  of  the  facial  nerve  may  be  caused  by  an  intra- 
cranial tumor  pressing  upon  the  facial  nerve  just  at  its  exit  in  the  cere- 
bellopontile  angle. 

Facial  Palsy.^ — ^The  facial,  or  seventh,  nerve  supplies  the  muscles  of 
the  face.  Its  nucleus  is  in  the  lower  and  posterior  portions  of  the  pons, 
and  the  nerve  in  its  course  outward  surrounds  the  nucleus  of  the  sixth 
nerve.  Its  exit  is  just  between  the  pons  and  medulla.  Because  of 
this  anatomical  relation,  any  gross  lesion  involving  the  seventh  nucleus 
will  nearly  always  involve  the  sixth,  and  vice  versa.  The  usual  form 
of  facial  palsy  is  that  known  as  peripheral,  or  Bell's,  palsy.  Lesions 
causing  this  may  be  either  in  the  pons,  at  the  exit  of  the  nerve,  at  the  base 
of  the  brain,  in  the  Fallopian  canal,  or  in  its  extracranial  course 

Central  facial  palsy  (Fig.  78)  is  that  form  of  facial  paralysis  in  which 
the  lower  part  of  the  face  only  is  paralyzed  and  is  the  result  of  a  lesion  in 
any  portion  of  the  central  facial  fibers  between  the  facial  centres  in  the 
cortex  and  its  nucleus  in  the  pons,  as,  for  instance,  in  a  capsular  hemiplegia. 


Spasm  of  right   facial  nerve. 


DISEASES  OF  THE  PERIPHERAL  NERVES 


217 


The  reason  for  the  escape  of  the  upper  portion  of  the  face  in  such  paralysis 
is  that  wrinkhng  the  brow,  in  common  with  other  bilateral  functions,  such 
as  chewing,  eating,  and  swallowing,  has  bilateral  cortical  innervation, 
and  to  cause  paralysis  of  such  functions  there  must  be  bilateral  cerebral 
lesions. 

In  a  large  majority  of  cases  ordinary  peripheral  facial  palsy  is  the 
result  of  a  neuritis  which  may  be  of  rheumatic  origin  or  may  follow  a 
"cold."  Rarely  it  is  due  to  basal  syphilis,  tumors,  fractures,  etc.  When 
resulting  from  a  lesion  in  the  pons,  facial  paralysis  is  generally  accom- 


Fitt.  78 


Right  central  facial  palsy  in   hemiplegia,   showing  drooping  of  the  right  corner  of  the  mouth. 
There  is  preservation  of  the  movements  of  the  brow. 

panied  by  other  symptoms,  such  as  palsy  of  the  sixth  nerve,  paralysis  of 
associated  ocular  movement,  or  hemiplegia  upon  the  other  side.  Abscess 
of  the  middle  ear  is  a  common  cause  as  well  as  mastoid  operations. 
When  the  lesion  is  in  the  Fallopian  canal  we  have  in  addition  to  the  usual 
symptoms  temporary  disturbance  of  taste  in  the  anterior  two-thirds  of 
the  tongue  because  of  involvement  of  the  chorda  tympani  which  runs 
along  with  the  seventh  nerve  in  the  Fallopian  canal  (Fig.  79). 

The  symptoms  of  peripheral  paralysis  of  the  facial  nerve  depend  upon 
the  degree  of  its  involvement.     When  the  paralysis  is  total  there  is 


218 


DISEASES  OF  THE  NERVOUS  SYSTEM 


inability  to  wrinkle  the  brow,  to  shut  the  eye,  to  elevate  the  corner  of  the 
mouth,  to  whistle,  or  to  pronounce  labials  properly.  Besides,  there  will 
be  drooping  of  the  lower  lid  and  of  the  corner  of  the  mouth,  and  the 
wrinkles  on  each  side  of  the  face  will  be  smoothed  out.  Because  of  the 
drooping  of  the  lower  lid  there  will  be  widening  of  the  palpebral  fissure 
and  excessive  flow  of  tears  because  of  the  lack  of  proper  conduction  into 
the  nasal  cavity.  Electrical  reactions  of  degeneration  will  be  found, 
their  degree  depending  upon  the  extent  of  the  neuritis.  Sensory  dis- 
turbances may  be  present  at  the  onset,  when  the  patient  may  complain 
of  pain  in  the  face,  and  there  may  also  rarely  be  herpetic  eruptions  in 
the  ear  because  of  involvement  of  the  geniculate  ganglion. 


Fig.  79 


Left  peripheral  facial  palsy,  showing  inability  to  wrinkle  brow  and  show  teeth  on  the 

paralyzed  side. 

Most  cases  of  peripheral  facial  paralysis  recover,  providing  the  cause 
is  an  ordinary  neuritis  such  as  results  from  "colds"  or  rheumatism  and 
prompt  treatment  is  instituted.  In  those  cases  in  which  the  nerve  is 
cut,  unless  an  anastomosis  is  performed,  recovery  cannot  be  expected. 
Sometimes  years  after  the  occurrence  of  such  paralysis  there  may  occur 
secondary  contractures. 

Torticollis  (Wry  Neck) . — Inasmuch  as  the  spinal  accessory  nerve  sup- 
plies the  sternomastoid  and  trapezius  muscles,  an  irritation  of  it,  such  as 
results  from  pressure,  will  cause  spasm  in  its  distribution,  or  torticollis. 
In  most  instances,  however,  the  cause  is  not  known.  It  may  come  on 
suddenly  as  the  result  of  fright,  but  usually  the  onset  is  gradual,  the 


NerJc  inUKcleit 


DISEASES  OF  THE  CERVICAL  NERVES  219 

spasm  growing  more  and  more  severe,  the  particular  kind  depending 
upon  the  muscles  involved.  If  the  sternomastoid  alone  is  involved,  the 
head  is  turned  to  the  opposite  side,  the  chin  pointing  a  little  upvi^ard ;  if  the 
trapezius,  the  head  is  retracted  toward  the  shoulder  on  the  same  side,  the 
chin  pointing  upward ;  if  both  the  sternomastoid  and  trapezius,  the  head 
is  turned  to  the  opposite  side,  backward,  and  the  chin  higher  than  when 
either  are  alone  diseased.  Very  often,  in  association  with  the  sterno- 
mastoid and  trapezius  muscles,  the  rotators  of  the  neck,  muscles  of  the 
shoulder,  the  rectus  capitis,  and  splenius  muscles  of  one  or  both  sides 
partake  in  the  spasm,  and  the  movements  are  complicated.  When  the 
rotators  alone  are  involved,  the  head  is  turned  toward  the  same  side, 
the  chin  being  on  a  straight  line;  when  the  splenius,  the  head  is  retracted, 
the  chin  upward,  differing  from  the  action  of  the  trapezius  in  the  fact  that 
in  the  latter  the  head  is  retracted  toward  the  shoulder.  When  both 
sternomastoids  are  involved  the  head  will  be  drawn  forward,  and  if  the 
movements  are  clonic  there  will  result  so-called  nodding,  or  salutatory, 
spasms,  which  are  especially  common  in  children.  The  spasms  may  be 
tonic,  when  it  is  difficult  to  return  the  head  to  its  original  position, 
or  clonic,  the  movements  being  intermittent.  Ordinary  stiff  neck,  or 
rheumatic  torticollis,  hardly  enters  into  the  discussion.  The  course  of 
the  disease,  as  a  rule,  is  long  and  the  prognosis  not  very  good.  It  is  best 
in  those  cases  in  which  treatment  is  instituted  early  and  in  which  absolute 
control  of  the  patient  can  be  obtained. 


DISEASES  OF  THE  CERVICAL  NERVES. 

Cervical,  or  Occipital,  Neuralgia. — The  first  four  cervical  nerves  are  some- 
times diseased  alone  or  in  association  with  the  cervical  nerves  which 
enter  into  the  brachial  plexus.  When  they  alone  are  diseased  and  the 
posterior  primary  divisions  are  involved,  there  will  be  pain  along  the  distri- 
bution of  the  great,  third,  and  small  occipital  and  the  auricularis  magnus 
nerves,  and  the  pain  will  be  very  marked  in  the  back  of  the  neck  and  scalp 
up  as  far  as  the  vertex.  Besides,  there  will  be  pain  on  pressure  over  this 
part  and  especially  over  the  exits  of  these  nerves.  The  pains  may  be 
constant  or  may  come  on  spasmodically  and  be  so  intense  as  to  prevent 
the  patient  from  moving  the  head  and  neck.  Occasionally  there  may 
be  dropping  out  of  the  hair  from  the  affected  scalp. 

Brachial  Neuritis. — ^The  brachial  plexus  is  composed  of  the  fifth,  sixth, 
seventh,  and  eighth  cervical  and  the  first  thoracic  roots,  and  supplies 
motion  and  sensation  to  the  upper  limb.  A  neuritis  may  involve  all  of 
the  branches  of  the  plexus  or  be  limited  to  its  parts,  especially  the  fifth 
and  sixth  cervical  or  the  seventh  and  eighth  cervical  and  the  first  thoracic 
roots  or  their  continuations.  There  may  be  in  association  with  this  an 
involvement  of  the  first  four  cervical  nerves,  when  it  is  called  a  cervico- 
brachial  neuritis.  If  the  whole  brachial  plexus  is  affected,  the  symptoms 
will  depend  largely  upon  the  severity  of  the  disease.  There  will  be  pain 
in  the  shoulder  and  the  axilla,  this  radiating  along  the  whole  arm,  and 


220  DISEASES  OF  THE  NERVOUS  SYSTEM 

pain  on  pressure  over  the  nerve  trunks.  In  fact,  there  will  be  pain  over 
the  whole  upper  limb,  and  any  movement  or  pressure  will  aggravate  it. 
In  association  with  this  neuritis  there  is  always  paralysis  either  of  a 
whole  or  of  a  part  of  the  upper  limb. 

If  the  upper  cords  of  the  brachial  plexus,  i.  e.,  the  fifth  and  sixth 
cervical  roots,  are  diseased,  the  pain  will  be  limited  to  the  neck,  shoulder 
and  to  the  arm  as  far  as  the  elbow,  there  being  pain  on  pressure  over  these 
parts;  if  to  the  lower  part  of  the  brachial  plexus,  i.  e.,  the  seventh  and 
eighth  cervical  and  first  thoracic  roots,  or  their  continuations,  the  pain 
will  be  limited  to  the  forearm  and  muscles  of  the  hand.  In  association 
with  both  these  types  of  neuritis  there  will  be  more  or  less  paralysis  in 
the  same  parts. 

Brachial  Neuralgia. — The  difference  between  brachial  neuritis  and 
neuralgia  is  that  in  the  latter  the  pains  are  spasmodic  in  character,  there 
is  pain  on  pressure  over  the  nerve  trunks  and  the  arm  only  at  the  time 
of  the  pains,  and  there  will  not  be  an  accompanying  paralysis. 

Brachial  Palsy. — Paralysis  of  the  brachial  plexus  may  be  total  or 
partial,  unilateral  or  bilateral.  If  total,  the  arm  hangs  limp  by  the  side, 
no  movements  being  possible;  the  muscles  are  atrophic,  electrical  reac- 
tions of  degeneration  are  obtained,  and  atrophic  phenomena  are  present. 
Partial  brachial  paralysis  may  be  either  of  the  upper  plexus  type,  the 
so-called  Duchenne-Erb  form,  in  which  the  fifth  and  sixth  cervical  roots 
or  the  fibers  in  the  plexus  coming  from  these  roots  are  involved,  or  the 
Klumpke,  or  lower  plexus,  type,  in  which  the  eighth  cervical  and  the  first 
dorsal  roots  are  diseased. 

In  the  upper  plexus  form  the  deltoid,  triceps,  brachialis  anticus,  the 
supinator  longus  and  brevis,  and  the  infraspinatus  muscles  are  affected. 
It  is  impossible  to  adduct  the  arm  and  the  forearm  is  extended  and  pro- 
nated.  Sensation,  as  a  rule,  is  not  disturbed.  The  muscles  are  atrophic, 
and  there  may  be  reactions  of  degeneration.  In  the  Khmipke  paralysis 
the  small  muscles  of  the  hand  and  a  number  of  muscles  of  the  forearm, 
especially  the  flexors,  are  paralyzed.  Sensory  disturbances  are  common 
in  the  hand  and  forearm,  especially  in  the  ulnar  distribution. 

These  different  types  of  brachial  plexus  paralysis  are  mostly  trau- 
matic in  origin,  and  may  be  due  to  blows,  gunshot  or  stab  wounds, 
fracture  of  the  head  of  the  humerus,  dislocation  of  the  shoulder,  and 
tumors.  The  so-called  obstetrical  and  most  narcosis  paralyses  are 
included  in  the  upper  arm  type.  The  disease  may  also  occur  idio- 
pathically,  the  cause  probably  being  toxic. 

Involvement  of  the  Sympathetic  System.  Ocular  Symptoms. — Oculo- 
pupillary  symptoms,  consisting  in  a  narrowing  of  the  pupil  and  of  the 
palpebral  fissure,  can  occur  only  if  the  first  dorsal  roots  are  involved 
either  in  the  intervertebral  foramen  or  before  their  separation  from  the 
rami  communicantes.  Therefore,  in  the  lower  arm  type  of  paralysis, 
in  which  the  eighth  cervical  and  the  first  dorsal  roots  are  diseased,  we 
always  have  oculopupillary  symptoms.  It  is  possible,  however,  to  have 
this  type  of  paralysis  without  sympathetic  involvement,  if  the  fibers 
in  the  brachial  plexus,  coming  from  these  roots  and  not  the  roots  them- 


DISEASES  OF  THE  CERVICAL  NERVES  221 

selves,  are  diseased.  It  is  difficult,  however,  to  make  such  a  clinical 
differential  diagnosis  because  the  symptoms  are  identical,  but  we  can 
always  assume  that  if  the  oculopupillary  symptoms  are  present  the  first 
dorsal  root  is  diseased. 

In  the  Duchenne-Erb  type  of  paralysis,  due  to  a  birth  palsy,  or  the 
paralysis  occurring  in  the  course  of  etherization,  the  traction  upon  the 
arms  may  cause  an  abnormal  stretching  and  tearing  of  the  rami  communi- 
cantes  of  the  first  dorsal  root,  thus  causing  sympathetic  paralysis  without 
the  first  dorsal  root  itself  being  diseased. 

If  all  of  the  roots  of  the  brachial  plexus  are  diseased  we  may  have 
oculopupillary  symptoms.  As  a  result  of  gunshot  or  stab  wounds  we 
may  have  forms  of  paralysis  which  do  not  conform  to  any  of  the  known 
types  with  sympathetic  symptoms.  In  these  cases  either  the  first  dorsal 
roots  are  involved  or  the  oculopupillary  fibers  in  the  cervical  sympathetic 
are  injured. 

Paralysis  of  the  Circumflex  Nerve. — ^This  results  from  dislocations  and 
injuries  to  the  shoulder,  and  produces  paralysis  of  the  deltoid  muscle 
with  accompanying  atrophy  and  inability  to  adduct  the  arm.  If  there 
is  a  neuritis,  there  will  be  pain  on  pressure  over  the  shoulder  and  dis- 
turbance of  sensation. 

Paralysis  of  the  Long  or  Posterior  Thoracic. — ^This  results  sometimes 
from  lifting  heavy  weights  or  injuries  and  dislocations  to  the  shoulder, 
and  causes  paralysis  of  the  serratus  magnus  muscle.  The  lower  edge 
of  the  scapula,  to  which  the  serratus  magnus  is  attached,  will  be  moved 
nearer  the  spine  and  become  very  prominent  and  there  will  be  inability  to 
lift  up  the  arm  more  than  to  the  horizontal  plane.  There  may  be  pain 
on  pressure  over  the  scapula  and  neck  and  disturbance  of  sensation. 

Musculospiral  Palsy. — ^This  nerve  is  very  frequently  injured  or  diseased 
because  of  its  exposed  position  around  the  humerus.  It  generally  is 
found  affected  after  a  debauch,  the  patient,  while  intoxicated,  lying  on 
his  arm,  thus  causing  pressure  and  paralysis.  It  is  sometimes  called 
"Saturday  night"  palsy.  There  is  wrist  drop  with  inability  to  extend 
the  fingers,  and  pain  on  pressure  over  the  nerve,  with  disturbance  of 
sensation  over  the  extensor  surface  of  the  arm. 

Median  Nerve  Palsy. — Median  nerve  palsy  is  generally  due  to  injuries. 
This  nerve  supplies  all  the  flexors  of  the  fingers,  the  flexor  carpi  radialis 
and  the  pronator  radii  teres,  and  its  paralysis  causes  inability  to  flex  the 
fingers  or  abduct  or  adduct  the  thumb  or  to  pronate  the  forearm.  There 
may  be  pain  on  pressure  over  the  nerve  and  some  sensory  disturbances 
over  the  palm  of  the  hand,  to  be  followed  later  by  atrophy  in  the  involved 
muscles. 

Ulnar  Palsy. — ^This  is  usually  produced  by  direct  injury  to  the  nerve. 
It  supplies  the  flexor  carpi  ulnaris,  the  ulnar  half  of  the  flexor  profundus 
digitorum,  the  muscles  of  the  hypothenar  eminence,  the  interossei, 
the  inner  three  lumbricales,  the  adductor  pollicis,  and  the  flexor  brevis 
pollicis.  In  ulnar  paralysis  there  is  disturbance  of  flexion  of  the  hand 
and  of  the  last  three  fingers,  inability  to  flex  the  proximal  and  extend 
the  terminal  phalanges  of  the  fingers.      This  is  especially  marked  in 


222  DISEASES  OF  THE  NERVOUS  SYSTEM 

the  last  two  fingers,  and  there  is  also  some  weakness  in  adduction  of 
the  thumb,  this  disturbance  causing  the  so-called  "claw  hand,"  it  being 
more  marked  later  when  there  is  atrophy  in  the  involved  muscles.  Sen- 
sory disturbances  are  not  frequent,  and,  when  present,  are  limited  to  the 
flexor  and  extensor  surfaces  of  the  last  two  or  three  fingers. 


DISEASES  OF  THE  THORACIC  NERVES. 

Intercostal  Neuralgia. — ^This  may  be  due  to  a  variety  of  causes,  the  symp- 
toms, as  a  rule,  being  unilateral.  There  is  spasmodic  pain  around  the 
chest  of  a  sharp,  shooting  character,  tenderness  over  the  nerve  and  over 
the  foramina,  and  sometimes  an  herpetic  eruption. 


DISEASES  OF  THE  LUMBAR  AND  SACRAL  NERVES. 

Only  very  rarely  are  the  plexuses  of  these  nerves  diseased  either  inde- 
pendently or  together.  The  most  frequent  nerves  to  be  affected  are  the 
sciatic  and  the  external  popliteal  and  its  divisions. 

Sciatica. — This  may  be  due  to  a  variety  of  causes.  If  there  is  neuritis, 
it  is  generally  rheumatic  in  origin  and  there  is  constant  pain  on  pressure 
over  the  whole  extent  of  the  nerve  along  the  back  of  the  thigh  and  leg 
as  far  as  the  ankle,  pain  on  pressure  over  the  nerve  trunk,  also  pain  when 
the  thigh  is  extended  on  the  abdomen,  causing  stretching  of  the  nerve. 
Because  of  the  pain  the  patient  in  walking  will  bend  to  the  opposite  side, 
and  sometimes  a  scoliosis  will  result  in  an  effort  to  save  the  diseased 
leg.  There  will  also  be  loss  of  the  Achilles  jerk.  Occasionally  there  is 
paralysis  of  the  muscles  below  the  knee. 

Paralysis  of  the  External  Popliteal  Nerve. — ^This  is  mostly  due  to  direct 
injury.  The  nerve  has  two  divisions,  the  peroneal  and  the  anterior  tibial. 
If  both  are  involved,  there  will  be  foot  drop  with  inability  to  dorsally  flex 
the  toes  or  foot  or  to  deviate  the  foot  outward.  If  the  peroneal  nerve  is 
involved  alone,  there  will  be  foot  drop,  with  inability  to  deviate  the  foot 
outward,  but  slight  dorsal  flexion  of  the  large  toe  will  be  possible.  If 
the  anterior  tibial  nerve  is  diseased,  it  will  be  impossible  to  dorsally  flex 
the  large  or  any  of  the  toes,  but  deviation  of  the  foot  outward  will  be 
possible. 

Tumors  of  the  Nerves. — These  are  of  rare  occurrence  and  are 
generally  fibromata,  but  sarcoma,  angioma,  or  any  of  the  other  usual 
forms  may  occur.  The  tumor  may  develop  within  or  upon  a  nerve 
sheath.  The  amputation  fibroneuroma  is  the  best  example  of  a  true 
nervous  tumor;  it  is  possible  that  pure  neuromata  do  not  exist. 

Fibroma  may  sometimes  grow  upon  one  nerve,  or  may  rarely  involve 
all  the  nerves  of  the  body,  even  the  cranial  nerves,  constituting  Reckling- 
hausen's disease. 


Miiycles  of  back 


CHAPTER    XII. 

THE  HEAD,  FACE,  AND  NECK. 
THE  HEAD. 

The  diagnosis  of  surgical  affections  of  the  skull  and  its  teguments 
and  accessory  cavities  is  considered  under  this  heading.  The  surgical 
affections  of  the  brain  and  its  envelopes,  except  those  which  are 
traumatic  and  acutely  infective,  are  discussed  under  affections  of  the 
nervous  system. 

The  diagnosis  of  traumatic  lesions  of  the  cranium  and  its  teguments 
is  important  mainly  only  so  far  as  it  concerns  the  presence  or  absence  of 
injury  to  the  brain  or  its  vessels  and  nerves. 

Contusion. — Head  injuries  of  this  nature  may  be  superficial,  in  which 
case  the  scalp  and  periosteum  alone  are  involved;  or  deep,  producing 
fractures  of  the  bone  and  lesions  of  the  brain  and  its  meninges.  The 
brain  may  exhibit  lesions  even  though  the  skull  has  not  been  fractured, 
the  resiliency  of  the  bony  case  being  sufficient  to  enable  it  to  withstand 
a  trauma  which,  by  suddenly  driving  in  a  part  of  its  walls,  bruises  or 
lacerates  the  brain  substance. 

Contusions  of  the  scalp  are  characterized  by  rapid  swelling  incident 
to  the  free  bleeding  which  is  dependent  upon  the  vascularity  of  the  part 
and  the  looseness  of  the  tissue  texture.  This  bleeding  commonly  takes 
place  in  the  subcutaneous  tissue.  It  then  forms  a  hard,  discolored, 
circumscribed  tumor,  movable  with  the  scalp. 

The  vessels  torn  may  lie  beneath  the  aponeurosis  of  the  occipito- 
frontalis  muscle  or  beneath  the  periosteum.  In  the  former  case  the 
swelling  is  less  sharply  defined,  and  in  both  instances  readily  pits  in  the 
centre,  and  does  not  move  with  the  aponeurosis.  It  may  present  around 
a  soft,  depressible  centre,  caused  by  the  impact  of  a  blow,  a  ring  of 
almost  bony  hardness,  due  to  coagulated  fibrin.  To  the  examining 
finger  the  sensation  is  so  like  that  characteristic  of  a  depressed  fracture 
of  the  skull  that  the  scalp  has  often  been  incised  and  raised  before  a 
correct  diagnosis  could  be  made.  It  is  usually  possible  to  form  a  non- 
operative  differential  diagnosis  by  making  firm  rubbing  pressure  con- 
tinued for  several  minutes  over  a  part  of  what  is  apparently  the  bony 
wall  of  the  depressed  fracture.  As  the  edema  and  coagulated  blood  are 
gradually  pressed  aside,  the  smooth,  unbroken  surface  of  the  skull  can 
be  felt. 

Contusions  of  the  scalp  in  the  frontal  region  are  commonly  followed  by 
swelling  and  ecchymosis  of  both  eyelids  from  gravitation  of  the  blood. 
When  a  comparatively  large  vessel  has  been  torn  a  pulsating  tumor  may 
be  formed,  or,  when  free  bleeding  occurs  beneath  the  aponeurosis,  there 


224  THE  HEAD,  FACE,   AND  NECK 

may  be  a  fluid  accumulation  which  can  be  pressed  from  the  occipital  to 
the  frontal  and  temporal  regions. 

From  infection  of  these  effusions  abscesses  or  cellulitis  may  develop. 
Usually  they  undergo  prompt  resolution;  exceptionally  they  persist  as 
fluctuating  tumors,  or  when  they  are  subperiosteal,  they  may  be  followed 
by  bony  outgrowth  sequent  to  bone  contusion ;  headache,  neuralgia,  and 
epilepsy  are  recorded. 

Depending  upon  the  position  and  extent  of  the  lesions  due  to  contusion 
of  the  brain,  this  condition  is  manifested  by  the  symptoms  of  concussion, 
of  focal  irritation,  or  of  compression. 

Concussion. — Concussion  is,  doubtless,  a  bruising,  even  though  the 
force  be  of  such  slight  degree  as  to  produce  no  demonstrable  lesions;  in 
its  severer  forms  the  gross  lesions  may  be  at  the  point  of  impact,  opposite 
to  this,  or  in  any  part  of  the  brain,  but  particularly  at  the  tips  of  the 
temporal  lobes  and  the  base  of  the  frontal  lobe. 

Concussion  may  be  slight,  moderate,  or  severe.  Slight  concussion 
is  characterized  by  a  momentary  confusion,  or  insensibility,  attended 
with  muscular  relaxation,  pallor,  and  a  feeble  pulse.  Nausea  and 
vomiting  often  accompany  return  to  consciousness.  The  symptoms 
are  similar  to  those  of  fainting  from  emotional  causes. 

Moderate  concussion  is  characterized  by  complete  loss  of  consciousness, 
pallor,  shallow  respiration,  feeble,  often  irregular  pulse,  muscular 
relaxation.  The  face  is  calm,  the  eyelids  closed,  the  pupils  dilated  and 
even.  There  may  be  an  evacuation  of  feces  and  urine.  In  a  few 
minutes,  or  within  the  hour,  consciousness  is  regained,  there  is  some 
nausea  and  vomiting,  and,  after  a  varying  period  of  muscular  weakness 
and  mental  irritability  and  confusion,  there  is  left  only  a  dull  headache. 
The  mental  impressions  immediately  preceding  the  concussion  are  often 
abolished. 

Severe  concussion  is  characterized  by  slow  and  incomplete  reaction 
from  the  symptoms  of  moderate  concussion.  It  may  terminate  fatally. 
The  primal  insensibility  is  followed  by  a  condition  of  stupor.  The  first 
incontinence  of  urine  and  feces  is  followed  by  retention,  with  overflow 
and  constipation.  The  patient  often  lies  on  his  side  with  flexed  limbs 
in  a  condition  of  hebetude  from  which  he  can  be  momentarily  aroused ; 
at  times  a  condition  of  cerebral  irritability  develops,  characterized  by 
peevishness,  restlessness,  and  active  deliriimi.  Gradually  consciousness 
is  regained,  but  clear  mind  and  efficient  memory  come  slowly.  The 
temperature  is  often  subnormal. 

Focal  Irritation. — ^The  intracranial  lesions  of  contusion  of  the  skull, 
if  definitely  localized,  are  most  likely  to  appear  in  the  cortical  gray 
matter  and  to  be  superficial.  Wlien  such  lesions  are  not  severe  enough 
to  destroy  function  and  produce  paralysis,  they  cause  focal  irritation. 
The  presence  of  localized  moderate  bruising  can  usually  be  determined 
only  when  such  foci  are  placed  in  or  near  the  motor  centres.  Thus 
localized  or  unilateral  twitchings,  convulsions,  or  paralysis  would  sug- 
gest contusion  and  bleeding  the  seat  of  which  would  be  determined  by 
an  application  of  the  general  principles  of  cerebral  localization.     The 


THE  HEAD 


225 


stupor  or  prolonged  irritability  following  concussion  is,  in  the  absence 
of  the  general  symptoms  of  increased  cerebral  pressure,  evidence  of 
a  focal  irritation  of  the  psychical  centres. 

Compression. — ^The  symptoms  of  acute  cerebral  compression  are 
caused  by  a  rapid  encroachment  upon  the  space  which  should  be  occupied 
by  the  brain.  When  compression  is  incident  to  contusion  and  follows 
such  an  injury  immediately  or  within  a  few  hours,  the  cause  of  the 
increased  intracranial  pressure,  if  not  dependent  upon  depressed  bone, 
must  necessarily  be  hemorrhage. 

Acute  traumatic  compression  of  the  brain- in  its  full  development  is 
characterized  by  coma,  tortuous  and  dilated  retinal  veins,  slow,  snoring 
respirations,  hard,  slow,  full 


Fig.  80 


pulse  (compensatory  increase 
in  blood  pressure),  paralysis, 
subnormal  temperature  in  the 
shock  period,  followed  usually 
by  slight  fever.  As  death  ap- 
proaches the  pulse  becomes 
weak  and  hurried,  the  respi- 
rations are  rhythmically  ir- 
regular (Cheyne-Stokes),  the 
pupils  dilate,  and  the  tem- 
perature rapidly  rises. 

The  hemorrhage  may  be 
extradural,  subdural,  or  cere- 
bral. Extradural  hemor- 
rhage, between  the  dura  and 
the  bone,  is  commonly  due 
to  laceration  of  the  anterior 
branch  of  the  middle  menin- 
geal artery.  This  injury  may 
occur  without  fissure  or  frac- 
ture of  the  bone,  and  excep- 
tionally from  the  vessel  on 
the  side  opposite  to  that 
which  is  directly  injured. 

The  specific   symptoms  of 
this   lesion  are  usually  masked  by  those  of  severe  concussion,  or  of 
compression  from  subdural  or  intracerebral  bleeding. 

When  this  is  not  the  case,  a  person  who  has  been  injured  by  a  blow 
which  caused  a  slight  transitory  condition  of  concussion  seems  entirely 
recovered  from  the  effect  of  the  violence,  except  for  the  slight  dulness 
and  muscular  weakness  which  are  the  invariable  sequelae  of  a  cerebral 
jar.  After  a  brief  interval,  usually  a  few  hours,  there  develops  a  severe 
headache  which  becomes  steadily  worse,  is  followed  by  nausea  and 
vomiting,  aphasia  if  the  lesion  be  on  the  left  side,  weakness  in  the  hand 
and  arm  then  in  the  leg  of  the  side  opposite  the  lesion,  stupor,  later 
twitching  and  convulsive  movement  which  involve  the  face,  hemiplegia, 
X5 


Compression  following  hemorrhage  from   the  middle 
m.eningeal  artery.     (Helferich.) 


226  THE  HEAD,  FACE,  AND  NECK 

increased  arterial  tension  and  slow  pulse,  coma,  Cheyne-Stokes  breathing, 
and  death.  The  pupils  are  at  first  contracted,  then  dilated,  particularly 
the  one  on  the  affected  side.     To  this  rule  there  are  exceptions. 

The  severe  headache  is  due  to  the  stripping  and  irritation  of  the  dura 
by  the  accumulating  clot;  the  aphasia,  unilateral  paresis,  twitching,  and 
paralysis  to  the  pressure  focused  over  the  motor  centres;  the  coma 
and  symptoms  of  cerebral  compression  to  the  general  increase  of  cerebral 
pressure.  Paralysis  of  the  cranial  nerves  of  the  affected  side  may  be 
caused  by  the  extravasated  blood  reaching  the  base  of  the  cranium  and 
pressing  upon  the  nerve  trunks. 

The  diagnostic  features  of  extradural  hemorrhage  following  trauma 
are,  then:  (1)  The  presence  of  a  contusion  in  the  temporoparietal  region; 
(2)  an  interval  of  freedom  from  symptoms  (hours)  followed  by  violent 
headache;  (3)  signs  of  pressure  over  the  motor  centres;  (4)  symptoms 
of  cerebral  compression. 

There  is  no  non-operative  way  of  determining  the  origin  of  the  bleeding. 
If  not  from  the  anterior  branch  of  the  middle  meningeal  artery  it  is 
usually  from  the  posterior  branch.  Neither  injury  to  the  sinus  nor 
the  other  dural  vessels,  which  may  be  torn  by  contusion,  is  likely  to 
cause  a  hemorrhage  which  will  dissect  up  the  dura  and  exert  an  irri- 
tating then  a  paralyzing  pressure  upon  the  motor  centres  before  it 
causes  symptoms  of  general  cerebral  compression. 

The  diagnosis  of  subdural  hemorrhage  can  often  be  made  by  lumbar 
puncture,  which  withdraws  a  blood-stained  fluid.  When  pressure 
symptoms  are  so  great  as  to  threaten  life,  it  should  be  made  by  a 
decompression  operation  in  one  or  both  temporal  regions  unless  the 
symptoms  of  focal  irritation  point  to  another  region. 

When,  after  an  injury  to  the  head,  it  is  necessary  to  distinguish  between 
concussion  and  compression,  it  should  be  borne  in  mind  that  concussion 
resembles  syncope,  with  the  insensibility  which  shortly  becomes  only 
partial,  relaxation,  feeble  pulse,  and  shallow  respirations  of  that  con- 
dition. The  diagnosis  of  pure  concussion  without  brain  lesion  can  be 
framed  only  when  a  patient  promptly  and  completely  recovers  from 
such  injury  without  headache,  confusion,  irritability  or  any  other  sign  or 
symptom  suggesting  a  departure  from  his  usual  mental  health.  Exten- 
sive lesions  may  be  accompanied  at  first  by  the  slightest  degree  of  con- 
cussion. Compression  in  addition  to  the  insensibility  is  attended,  at 
least  in  its  earlier  stages,  with  a  full,  hard  pulse,  a  slow,  snoring  respira- 
tion, and  often  hemiplegia. 

Following  cerebral  hemorrhage,  whether  this  be  spontaneous  or  due 
to  trauma,  in  the  course  of  from  one  to  three  days  there  is  an  edema 
which,  if  diffuse  and  sufficiently  pronounced  to  interfere  with  cerebral 
circulation,  accentuates  the  symptoms  of  compression  should  they  have 
been  present;  or,  in  case  of  localized  trauma  attended  with  symptoms 
of  slight  concussion,  causes  mental  confusion,  delirium,  stupor,  or  the 
slowed  pulse  and  congested  tortuous  retinal  veins  of  pronounced 
compression. 

Aside   from    the   complications   due  to    infection,   i.   e.,  meningitis. 


TitE  HEAD  227 

encephalitis,  and  abscess,  there  may  follow  contusion  of  the  brain  either 
immediately  or  after  a  long  interval ;  headache,  which  may  be  so  severe 
and  persistent  as  to  be  crippling;  loss  of  the  senses  of  smell  and  taste; 
neurasthenia  with  its  typical  inconstancy  and  multiplicity  of  symptoms; 
loss  of  memory  and  inability  for  mental  application;  impotence,  palsies, 
traumatic  epilepsy,  insanity. 

Birth  Injuries  of  the  Head. — The  cafut  succedaneum,  a  rounded, 
pitting,  non-fluctuating,  edematous  swelling  of  the  soft  parts,  usually 
in  the  occipitoparietal  region,  has  attained  its  maximum  at  birth  and 
shortly  disappears. 

Cephalhematoma,  due  to  subpericranial  bleeding  and  incident  to 
difficult  labor,  is  characterized  by  the  development  after  birth  and  often 
progressive  increase  in  size  for  several  days,  of  a  fluctuating  cranial  area, 
sometimes  bilateral,  irregular  in  peripheral  contour,  and  corresponding 
with  that  of  the  ossified  portion  of  the  underlying  bone,  usually  the 
parietal.     Absorption  may  be  slow  (weeks)  or  the  tumor  may  persist. 

Indentation  and  fracture  of  the  cranial  hones,  usually  accompanied 
by  obvious  deformity,  is  of  importance  as  indicating  probable  subdural 
hemorrhage  and  brain  lesion. 

Intracranicd  hemorrhage,  usually  subdural,  is  characterized  by  promi- 
nent fontanelles,  dilatation  of  the  surface  veins  and  those  of  the  retina, 
slow  or  irregular  pulse,  irregular,  at  times  Cheyne-Stokes,  respiration, 
inability  to  suckle,  twitchings  or  convulsions. 

The  absolute  diagnosis  must  be  made  by  exploration. 

Fracture  of  the  Skull. — Fractures  of  the  skull  are  conveniently 
classed  as  of  the  vault  and  of  the  base.  They  may  be  partial,  involving 
either  the  external  or  internal  table,  or  complete,  involving  the  entire 
thickness  of  the  bone.  They  may  be  simple  or  compound,  fissured 
without  displacement,  or  depressed.  Depressed  fractures  are  formed 
at  the  seat  of  impact;  fissured  fractures  commonly  extend  from  this, 
but  may  through  their  entire  course  be  remote  from  it. 

Fractures  of  the  Vault. — When  these  injuries  occur  as  the  result  of  con- 
tusions, they  may  be  positively  diagnosticated  provided  there  is  depression, 
crepitus,  and  a  cracked-pot  percussion  note.  This  depression  must 
not  be  mistaken  for  that  sometimes  noted  in  simple  contusion  of  the 
scalp.  The  yielding  of  the  broken  bone  when  it  is  not  impacted,  the 
sharp,  irregular  edge  of  the  depression,  and  the  impossibility  of  affecting 
the  bony  margins  of  the  depression  by  steady,  continuous  massage  and 
pressure,  are  signs  peculiar  to  depressed  fracture.  Skull  deformity 
incident  to  previous  lesions  should  not  mislead.  A  fissured  fracture  of 
the  vault  without  displacement  can,  in  the  absence  of  a  wound,  be 
detected  only  by  exploratory  incision  or  the  x-rays.  It  may  be  suggested 
by  persistent  bone  tenderness. 

When  the  fracture  is  compound  the  area  of  depression  can  be  both 
seen  and  felt.  A  moderate  depression  may  involve  the  outer  table 
alone.  Over  the  frontal  sinuses  a  pronounced  depression  may  be 
present  without  involving  the  inner  walls  of  these  cavities.  This  can 
be  determined  only  by  the  use  of  the  trephine. 


228 


THE  HEAD,  FACE,  AND  NECK 


Fissured  fractures  are  manifested  by  a  sharply  marked  blood-stained 
line  running  through  the  bone.  Often  there  is  a  distinct  edge  from 
slight  inward  displacement  of  one  fragment.  Fracture  of  the  inner 
table  without  lesion  to  the  outer  may  possibly  be  detected  by  the  x-rays ; 
such  fractures  are  much  rarer  than  fractures  of  the  outer  table  without 
injury  to  the  inner. 

Fractures  of  the  Base. — These  are  caused  by  force  applied  to  the 
vault,  by  force  applied  through  the  spinal  column,  as  from  the  jamming 
down  of  the  skull  incident  to  a  heavy  fall  upon  the  buttocks,  or  by  the 
direct  penetration  of  a  vulnerating  body,  as  a  bullet  or  foil. 


Fig.  81 


Fig.  82 


Bursting  fracture  of  the  base. 
(Von  Bergmann.) 


Circular  fracture  of  the  base. 
(Von  Bergmann.) 


The  diagnostic  features  of  fracture  of  the  base  of  the  skull  are:  Per- 
sistent bleeding  followed  by  a  flow  of  cerebrospinal  fluid  from  the  nose, 
mouth,  and  ears,  paralysis  of  one  or  more  of  the  cranial  nerves,  and 
usually  the  symptoms  of  cerebral  concussion  or  compression.  All  three 
fossse  are  often  fractured. 

Fractures  of  the  anterior  fossa  are  commonly  due  to  force  applied  to 
the  front  part  of  the  cranial  vault.  The  first  characteristic  symptom 
is  free  persistent  bleeding  from  the  nose;  the  blood  may  trickle  back 
into  the  pharynx,  and  may  be  followed  after  some  hours  by  a  slow, 
steady  flow  of  cerebrospinal  fluid. 

This  escape  of  cerebrospinal  fluid  from  the  nose  is  diagnostic  of 
fracture  of  the  ethmoid  or  the  body  of  the  sphenoid.  In  the  former  case 
there  is  exceptionally  loss  of  the  sense  of  smell;  in  the  latter  there  may 
be  partial  or  complete  paralysis  of  the  optic  nerve,  causing  blindness,  or 
of  the  oculomotor  nerves,  causing  dilatation  of  the  pupil  and  divergent 
strabismus. 

The  bleeding  must  be  distinguished  from  that  due  to  fracture  of  the 


PLATE  XII 


Fractures  of  the  Base  of  the  Skull.       Illustrative  lines  of  fissure  or  fracture 
are  printed  in  red.     (Park.) 


THE  HEAD 


229 


vomer  or  lesion  of  the  mucous  membrane  of  the  nose.  In  fracture  of 
the  nasal  bone  the  force  is  commonly  applied  directly  to  the  bridge  of  the 
nose;  in  fracture  of  the  base  of  the  skull  the  force  is  applied  to  the 


Fig.  83 


Fig.  84 


Longitudinal  fracture  of  the  base. 
(Von  Bergmann.) 


Fracture  of  base,  from  fall  from  scaffolding. 
Hemorrhage  from  right  ear  and  nose.  Death 
from  meningitis.      (Von  Bergmann.) 


anterior  temporal  or  the  frontal  region.  Fig.  85 

Fracture  of  the  nasal  bones  can  be  de- 
tected by  direct  examination,  and  some- 
times the  mucous  membrane  lesions 
and  the  source  of  bleeding  can  be 
seen  with  the  rhinoscope.  The  bleed- 
ing of  fracture  of  the  nasal  bones  is 
commonly  free  at  first,  but  is  less  likely 
to  be  persistent  and  is  not  followed 
by  a  steady,  persistent  oozing. 

When  the  fracture  involves  the 
roof  of  the  orbit,  there  may  develop 
shortly  a  projection  of  the  eyeball, 
and  after  one  or  two  days  sub- 
conjunctival ecchymosis  followed  by 
palpebral  discoloration.  The  blood 
lies  beneath  the  ocular  conjunctiva  and 
not  in  its  substance,  is  dark  in  color, 
and  reaches  the  lids  after  it  has  ap- 
peared beneath  the  ocular  conjunctiva. 
This  symptom  is  not  pathognomonic. 

Fractures  of  the  middle  fossa,  commonly  due  to  violence  applied  to 
the  parietal  or  the  temporal  region,  is  characterized  by  free^  persistent 


Bursting  fracture.  Patient  slipped, 
striking  head  on  a  stone.  Direction  of 
force  indicated  by  arrow.  (Von  Berg- 
mann.) 


230  THE  HEAD,  FACE,  AND  NECK 

bleeding  from  the  ear,  followed  by  an  oozing  of  cerebrospinal  fluid. 
There  is  sometimes  facial  palsy  and  deafness.  The  line  of  fracture  is 
likely  to  run  in  the  long  axis  of  the  petrous  portion  of  the  temporal  bone. 

When  the  violence  is  applied  to  the  occipital  region,  the  fracture  is 
likely  to  be  transverse;  and  in  this  case  all  these  symptoms  are  more 
marked,  especially  the  flow  of  cerebrospinal  fluid;  deafness  and  facial 
palsy  are  more  commonly  developed. 

Fractures  involving  the  apex  of  the  petrous  portion  of  the  temporal 
bone  may  cause  paralysis  of  the  sixth  (abducens)  nerve,  with  convergent 
squint  of  the  affected  side.  This,  a  common  paralysis,  is  observed 
after  comparatively  slight  injuries  and  may  be  transitory.  Facial 
palsy  is  peripheral  in  type.  It  may  be  observed  immediately  after 
the  injury,  in  which  case  it  is  due  to  contusion  or  rupture  of  the 
nerve  and  is  often  irreparable;  it  more  commonly  develops  in  a  few 
days,  and  is  then  due  to  pressure  incident  to  the  congestion  of  bone 
repair,  and  is  self-limited. 

Free  bleeding  from  the  ear  is  not  necessarily  a  sign  of  basilar  fracture. 
The  blood  may  come  from  a  fracture  involving  the  external  auditory 
meatus,  such  injury  being  usually  inflicted  by  a  blow  on  the  point  of  the 
chin,  which  drives  the  condyles  upward  and  backward;  or  the  blood 
may  come  from  a  ruptured  tympanic  membrane.  In  either  case  exami- 
nation with  an  otoscope  will  show  the  source  of  the  bleeding.  In  the 
latter  case  the  hemorrhage  is  likely  to  be  slight  and  soon  stops;  more- 
over, it  is  not  followed  by  the  escape  of  cerebrospinal  fluid. 

The  discharge  of  the  fluid  from  the  ear  may  be  slight,  lasting  but  a 
few  hours,  or  may  be  profuse,  lasting  for  a  week  or  more.  It  is  the  most 
constant  pathognomonic  sign  of  fracture  of  the  middle  fossa. 

Fractures  of  the  posterior  fossa  of  the  skull,  unless  compound,  present 
no  diagnostic  features.  The  violence  causing  such  injury  is  applied 
to  the  back  of  the  head,  as  from  a  fall  on  the  occiput  or  the  base  of  the 
skull,  or  from  the  jar  incident  to  a  fall  on  the  feet  or  the  buttocks. 
When  there  has  been  no  direct  trauma  to  this  region,  ecchymosis  above 
the  mastoid  and  in  the  back  of  the  neck,  developing  two  or  three  days 
after  traumatism,  would  be  suggestive  of  fracture.  Effusion  of  blood 
and  cerebrospinal  fluid  behind  the  posterior  wall  of  the  pharynx  is 
positively  diagnostic  when  it  is  practicable  to  detect  it. 

Compound  fracture  of  the  vault,  as  well  as  marked  fissured  fracture 
of  the  base,  may  be  attended  with  a  slight  transitory  concussion;  while 
fatal  contusion  of  the  brain  naay  be  caused  by  a  trauma  which  does  not 
fracture  the  bones.  In  itself,  fracture  of  the  skull  is  an  injury  of  minor 
importance.  The  need  of  determining  its  presence  is  dependent  upon 
the  immediate  and  remote  brain  lesions  it  may  cause  either  by  direct 
pressure  or  by  opening  the  route  to  infection. 

Traumatic  Encephalohydrocele. — In  infancy,  the  softness  of  the  bones 
aUows  of  great  depression  without  fracture,  and  this  same  quality 
prevents  the  extension  of  fissures  from  the  vault  to  the  base.  The 
elasticity  of  the  bones  of  the  vault  allows  of  the  infliction  of  a  severe 
contusion  or  fracture  without  any  of  the  deforming  incident  to  the  latter. 


THE  HEAD  231 

As  a  result  of  such  injury  or  of  disjunction  of  the  sutures,  trau- 
matic encephalocele  or  enceplialohydrocele  may  develop.  The  en- 
cephalocele  develops  immediately.  The  encephalohydrocele  weeks  or 
months  after  the  injury. 

The  characteristic  features  of  encephalohydrocele  are  a  history  of 
injury  to  the  head  of  an  infant  and  the  formation  of  a  fluctuating 
pulsatile  tumor  which  becomes  tense  on  expiration  and  on  straining, 
which  is  more  or  less  reducible,  and  which  contains  cerebrospinal 
fluid. 

Wounds  of  the  Cranium. — Wounds  of  the  cranium  may  be  non- 
penetrating or  penetrating.  The  diagnosis  of  non-penetrating  wounds 
of  the  scalp  is  obvious.  Contused  wounds,  such  as  those  inflicted  by  a 
club,  often  present  the  appearance  of  a  clean  incision  with  the  exception 
of  a  slight  line  of  abrasion  along  the  skin  edge.  Involvement  of  the  bone 
is  determined  by  inspection  and  palpation  when  the  wound  is  an  open 
one;  by  probing  and  enlarging  the  opening  when  the  scalp  is  simply 
punctured. 

When  such  wounds  refuse  to  heal,  a  discharging  sinus  persisting  at  or 
near  the  seat  of  injury,  a  careful  search  will  nearly  always  show  the 
presence  of  dead  bone  or  a  foreign  body,  as  a  splinter  of  wood. 

Penetrating  Wounds  of  the  Cranium. — ^The  diagnosis  of  penetration 
may  be  difficult  to  establish,  as  in  the  case  of  a  blow  on  the  head  with 
the  small  blade  of  a  penknife,  or  the  thrust  of  a  stick  into  the  orbit  or 
the  nose,  or  through  the  roof  of  the  mouth.  Such  wounds  are  excep- 
tionally followed  by  a  hemorrhage  so  free  as  to  produce  compression, 
either  immediately  or  within  a  few  hours.  Commonly  the  first  sign 
of  penetration  is  the  development  of  a  meningitis  or  encephalitis  (hours, 
days).  Exceptionally  there  is  an  interval  of  weeks  or  months  in  which 
there  are  no  symptoms,  followed  by  the  symptoms  of  brain  abscess. 

Penetration  in  case  of  punctured  wounds  of  the  vault  is  best  established 
by  an  exploratory  operation,  the  scalp  being  raised,  and,  should  there 
still  be  a  doubt,  a  button  of  bone  being  removed.  Where  punctures  of 
the  roof  of  the  orbit  are  suspected  but  cannot  be  verified  by  the  probe 
a  two-inch  incision  just  beneath  the  superciliary  ridge  carried  down  to 
the  bone  and  deepened  by  blunt  dissection  along  the  surface  of  the 
orbital  plate  will  enable  the  surgeon  to  determine  the  presence  of  a 
puncture  in  it.  Punctures  through  the  nose  or  palate,  if  not  followed 
by  immediate  cerebral  symptoms,  and,  if  their  presence  cannot  be 
determined  by  probing,  can  be  suspected  only  from  the  nature  of  the 
injury  and  the  character  of  the  vulnerating  body. 

Traumatic  prolapse  of  the  brain  is  characterized  by  the  appearance 
of  brain  matter  through  a  fracture,  usually  of  the  vault  of  the  skull. 
There  may  be  escape  of  brain  substance  from  the  orbit  or  the  ear  or  the 
nose.  The  prolapse  may  occur  immediately  or  may  be  secondary  to  the 
increase  of  intracranial  pressure  incident  to  trauma  or  infection.  It 
forms  a  soft,  gray,  pulsatile,  partly  reducible  tumor.  The  diagnosis  is 
based  on  the  macroscopic  appearance  and  on  microscopic  examination. 

Fungus  cerebri  is  a  mushroom-like  growth  made  up  of  granulation 


232  THE  HEAD,  FACE,  AND  NECK 

tissue  and  broken-down  blood  clot.  It  is  caused  by  infection  and 
grows  from  beneath  the  dura.  It  forms  a  sloughing,  vascular,  pulsating, 
suppurating  tumor  which  exhibits  a  marked  tendency  to  overlap  the 
opening  through  which  it  projects.  Unless  complicated  by  diffuse 
encephalomeningitis  it  causes  no  symptoms.  Fungus  cerebri  develops 
more  slowly  than  cerebral  prolapse,  is  always  caused  by  infection,  and 
a  microscopic  section  of  excised  portions  shows  the  traces  of  brain 
substance. 

Gunshot  wounds  of  the  cranium  are  usually  penetrating.  The  bullet 
commonly  pursues  a  straight  course;  exceptionally  it  is  deflected,  pro- 
ducing a  contusion  of  the  bone,  a  fracture  of  the  outer  or  inner  table,  or  a 
complete  fracture,  the  missile  then  passing  between  the  bone  and  the 
scalp.  The  fact  of  penetration  is  determined  by  the  probe.  When 
this  fact  is  established,  the  course  and  length  of  the  wound  track  and 
the  position  of  the  ball  remain  to  be  determined.  The  majority  of  gun- 
shot wounds  of  the  brain  are  inflicted  by  revolvers  of  22,  32,  38,  or  44 
caliber.  In  the  cheaper  weapons  of  these  calibers  the  penetration  is 
poor  and  varies  greatly.  The  best  weapon  at  close  range  may  be  counted 
to  carry  a  22  ball  through  the  skull  and  into  the  brain;  a  32  ball  through 
the  brain  to  the  opposite  side  of  the  skull,  producing  a  comminuted 
fracture  at  this  point;  a  38  ball  through  and  through,  or  through  the 
bone  and  to  the  skin  of  the  opposite  side;  a  44  ball  through  and  through, 
passing  out  at  a  wound  of  exit. 

The  bullet  of  the  air  rifle  and  the  22  Flobert  can  penetrate  the  brain 
through  the  orbit,  or  through  the  thinnest  part  of  the  temporal  bone. 

The  ball,  after  it  has  penetrated  the  skull,  usually  pursues  a  straight 
course.  If  it  reaches  the  opposite  side  of  the  skull,  it  may  pass  through, 
may  remain  at  the  point  of  impact,  or  may  rebound  or  glance.  Its 
position  is  best  determined  by  the  a;-rays. 

Meningitis  is  not  infrequently  a  complication  of  compound  fractures, 
including  those  of  the  base. 

Acute  osteomyelitis  after  fracture  of  the  posterior  fossa  is  a  rare 
complication.  In  the  absence  of  an  overshadowing  meningitis  it  is 
characterized  by  the  constitutional  signs  of  sepsis,  rigidity  of  the  neck 
muscles,  severe  pain  radiating  down  the  neck,  and  edematous  swelling  of 
the  posterior  pharyngeal  wall. 

Inflammatory  Affections  of  the  Scalp  and  Cranium. — The  usual 
acute  superficial  infections  include  furuncle,  carbuncle,  abscess,  and 
cellulitis.  The  diagnosis  is  based  upon  the  obvious  symptoms.  Acute 
osteomyelitis  is  characterized  by  the  violence  of  constitutional  symptoms 
which  precede  obvious  local  manifestations  aside  from  deep  pain,  tender- 
ness, and  edema. 

The  chronic  infections  are  exceptionally  tuberculous,  usually  syphilitic,, 
or  incident  to  infection  of  a  sebaceous  cyst. 

Of  the  superficial  skin  lesions  of  the  chronic  type,  those  commonly 
encountered  on  the  scalp  are  seborrhea,  in  both  its  dry  and  oily  forms 
(p.  91),  eczema,  and,  in  children,  tinea  and  the  lesions  incident  to 
pediculi. 


THE  HEAD  233 

Furuncles  disseminated  over  the  scalp,  if  painless,  chronic,  and 
without  peripheral  redness  and  edema,  are  usually  manifestations  of 
secondary  syphilis. 

Abscess  of  the  scalp,  usually  due  to  infection  of  an  undrained  wound 
or  of  a  hematoma,  is  heralded  by  an  increase  of  swelling  and  edema, 
together  with  pain,  heat,  and  redness.  After  the  first  twenty-four  hours 
a  wound  or  contusion  should  steadily  grow  less  painful  and  tender,  and 
after  forty-eight  hours  there  should  be  a  rapid  diminution  in  the  swelling. 
When  this  is  not  the  case,  infection  should  be  suspected.  The  absolute 
diagnosis  is  established  by  opening  a  wound  which  has  closed,  or  by 
incision.  Pus  in  appreciable  quantities  is  rarely  present  before  the 
third  day. 

Superficial  cellulitis,  or  cutaneous  erysipelas  of  the  scalp,  is  charac- 
terized by  a  hot,  red,  tender,  edematous  area  of  skin  with  raised, 
irregular,  well-marked  borders.  Its  tendency  is  toward  rapid  exten- 
sion and  it  often  involves  the  entire  scalp.  It  may  be  secondary 
to  the  superficial  infection.  It  commonly  follows  infected  wounds 
involving  the  aponeurosis  and  the  periosteum.  If  it  reaches  the  ear  and 
forehead,  small  vesicles  may  develop  in  the  skin,  and  the  upper  eyelids 
become  greatly  swollen.  The  lymphatic  ganglia  in  the  neck  are 
promptly  enlarged.  It  is  inaugurated  by  chill,  fever,  and  vomiting, 
and  is  often  accompanied  by  intense  headache,  sometimes  by  de- 
lirium. 

It  is  characterized  by  the  rapidly  spreading  area  of  heat,  tenderness, 
and  edematous  swelling  and  the  constitutional  symptoms  of  pronounced 
sepsis,  often  inaugurated  by  a  chill.  It  has  for  its  chief  danger  com- 
plicating osteomyelitis  or  suppurative  meningitis. 

Tuberculosis. — ^Tuberculous  ulceration  of  the  scalp  (rare),  secondary 
to  tuberculous  osteomyelitis  of  the  cranial  bones,  is  a  disease  of  early 
childhood,  and  is  nearly  always  associated  with  other  more  obvious 
tuberculous  lesions.  Local  pain  and  tenderness  are  followed  by  the 
development  of  a  flaccid,  fluctuating  tumor,  without  peripheral  indura- 
tion, which  slowly  opens  at  one  point  and  discharges  tuberculous  pus. 
Through  the  resulting  sinus  may  be  felt  a  sequestrum  usually  formed 
at  the  expense  of  the  entire  thickness  of  the  bone,  leaving  a  round 
perforation  without  surrounding  hyperostosis,  through  which  the  pulsa- 
tions of  the  brain  may  be  communicated  to  the  abscess  before  it  is 
opened.  The  frontal,  parietal,  and  temporal  bones  are  the  usual  seats 
of  this  rare  affection. 

The  ethmoid,  body  of  the  sphenoid,  and  petrous  portion  of  the  tem- 
poral bone  are  secondarily  affected  by  tuberculous  processes  extending 
from  the  nasal  cavity  or  the  middle  ear. 

The  symptoms,  if  any,  would  be  those  of  tuberculous  meningitis, 
or  of  pressure  from  abscess,  or  of  bleeding  incident  to  erosion. 

Syphilis. — ^The  papular  and  pustular  lesions  of  secondary  syphilis 
are  common  on  the  scalp,  usually  as  a  part  of  a  general  eruption. 

Nodules  on  the  frontal  and  parietal  bones,  causing  harassing  and 
even  agonizing  pain,  and  extremely  sensitive  to  pressure,  develop  in  the 


234  THE  HEAD,  FACE,   AND  NECK 

early  period  of  secondary  syphilis,  appearing  at  times  even  before  the 
exanthemata. 

Gummata  of  the  scaly  are  characterized  by  small  copper-colored, 
usually  painless,  nodules,  which,  in  the  absence  of  treatment,  break 
down,  forming  small,  punched-out,  wormeaten,  indolent  ulcers,  rounded 
in  shape,  grouped,  sometimes  confluent.  They  are  commonest  in 
the  frontal  region  near  the  hair  line  and  on  the  top  of  the  head.  The 
persistence  of  an  ulcer  in  these  regions  is  in  itself  suggestive. 

Distinction  from  a  non-ulcerating  sebaceous  cyst  is  difficult  in  the 
absence  of  a  history. 

Gummata  of  the  cranial  hones,  affecting  chiefly  the  frontal  and  parietal 
region,  and  developing  in  the  third  year  of  the  disease  or  much  later, 
are  often  characterized  by  agonizing,  generally  local,  pain,  which  becomes 
worse  toward  evening. 

When  the  infiltration  is  pericranial,  one  or  many  small  dense  tumors 
may  be  felt  through  the  scalp,  which  at  first  is  perfectly  normal,  and 
freely  movable  over  them.  These  tumors  may  disappear,  leaving 
distinct  depressions  in  the  bone,  or,  the  scalp  becoming  adherent,  they 
may  ulcerate  and  discharge  a  gummy  pus.  Dead  bone  can  be  felt  by 
probing  the  sinuses,  but  sequestra,  which  may  be  extensive,  show  little 
tendency  to  separate.  Together  with  the  destructive  process  there 
is  a  formative  one,  the  bone  becoming  thicker  about  the  lesion  and 
exostosis  developing. 

Gummata  which  develop  from  the  dura  mater  are  marked  by  pain 
more  intense  than  that  which  accompanies  the  pericranial  infiltra- 
tion, vertigo,  poor  mentality,  and  later  by  convulsive  seizures  which 
may  be  general  or  focal,  and  partial  palsies.  Should  the  gumma  soften, 
break  through  the  cranial  bone,  and  form  a  fluctuating,  partially  reducible 
tumor,  the  diagnosis  would  be  obvious.     This  penetration  is  rare. 

The  history  of  an  hereditary  or  acquired  infection,  the  presence  of 
other  syphilitic  lesions  or  their  traces,  the  induration  preceding  ulcera- 
tion, the  seat  of  the  lesions,  the  age  of  the  patients,  the  chronic  course, 
the  persistence  of  the  sequestra,  the  anfractuous  borders  of  the  osseous 
lesions,  the  absence  of  febrile  reaction,  and  the  prompt  effect  of  specific 
treatment  are  features  which  characterize  the  cranial  lesions  of  syphilis. 

Tuberculous  lesions,  in  addition  to  being  much  rarer,  affect  children 
who  usually  show  other  unmistakable  lesions  of  tuberculosis.  The 
sequestra  often  come  away  spontaneously  and  there  is  no  exostosis  or 
other  formative  process  about  the  borders  of  the  lesion. 

The  ulcerating  gummata  of  hereditary  syphilis,  commonly  placed 
about  the  bregma,  are  much  commoner  than  are  the  tuberculous  infiltra- 
tions in  this  region. 

Acute  suppurative  osteomyelitis  is  evidenced  first  by  the  sudden 
onset  of  an  agonizing  headache,  local  tenderness  to  tapping  and  deep 
pressure,  the  constitutional  symptoms  of  violent  sepsis,  and  local  edema 
which  shortly  becomes  diffuse  and  exhibits  the  softening  of  suppura- 
tion. This  acute  bone  infection,  commonest  during  or  before  adolescence, 
is  usually  secondary  to  wounds  or  contusion,  but  may  occur  without 


THE  HEAD  235 

appreciable  cause.     Its  violent  onset  and  rapid  progression  are  char- 
acteristic. 

From  a  localized  meningo-encephalitis  the  diagnosis  in  severe  cases 
may  be  impossible,  probably  because  this  is  a  common  complication. 

With  the  exception  of  the  pachymeningitis  of  sunstroke,  alcohol,  or 
syphilis,  characterized  chiejfly  by  persistent  headache  lasting  months  or 
years,  it  may  be  assumed  that  the  encephalon  is  more  or  less  involved 
in  all  inflammations  of  its  envelope. 

Acute  Leptomeningitis. — Acute  leptomeningitis,  traumatic,  second- 
ary to  an  infection  of  neighboring  structures  or  of  systemic  origin,  is 
usually  inaugurated  by  intense  headache,  chill  or  vomiting,  or  both, 
rapid  pulse  and  high  fever,  often  hypersensitiveness  of  the  special  senses, 
muscular  twitchings,  and  active  delirium  or  a  condition  of  apathy  or 
somnolence.  The  most  characteristic  features  of  the  affection  are  either 
general  or  local  contractures,  particularly  of  the  postcervical  group  of 
muscles,  keeping  the  head  back  and  rigidly  extended,  and  convulsions, 
followed  by  paralysis,  which  may  be  local  and  thus  localizing.  In  pro- 
gressive cases  the  delirium  or  somnolence  is  succeeded  by  coma,  irregular, 
hurried  pulse,  and  disturbed,  often  Cheyne-Stokes,  respiration.  The 
course  of  the  affection  in  its  ordinary  surgical  form  is  rapid.  Pronounced 
temporary  improvement  followed  by  relapse  is  not  uncommon. 

The  development  of  rigidity  of  the  postcervical  muscles  and  paralysis 
of  the  facial,  the  oculomotor,  or  the  abducens  nerve  point  to  a  basilar 
meningitis. 

In  framing  the  diagnosis,  a  history  of  a  preceeding  contusion  or  com- 
pound fracture  is  of  importance.  The  absolute  diagnosis  not  only  as 
to  the  presence  of  meningitis,  but  the  form  of  infection  producing  it, 
can  usually  be  made  by  lumbar  puncture.  High  fever  and  leukocytosis 
are  suggestive  but  not  absolutely  diagnostic  of  the  non-infectious  serous 
form  of  acute  leptomeningitis. 

Secondary  leptomeningitis,  exceptionally  consequent  to  suppurative 
lesions  of  the  scalp  or  the  cranial  bones,  is  particularly  likely  to  com- 
plicate osteomyelitis,  mastoid  disease,  or  suppuration  of  the  middle  ear 
or  infection  of  the  frontal,  ethmoidal,  or  sphenoidal  cells.  It  occurs 
in  the  course  of  pyemia,  pneumonia,  typhoid,  or  any  general  infection. 
The  symptoms  do  not  differ  from  those  already  given. 

Tuberculous  meningitis  (p.  202)  is  characterized  by  a  prodromal  period 
of  ill  health  and  the  absence  of  a  sufficient  traumatic  or  local  infective 
cause.  Its  development  in  early  childhood,  or,  if  in  adult  life,  its  practi- 
cally invariable  association  with  tuberculous  lesions  of  other  parts  of  the 
body,  its  almost  constant  association  with  strabismus,  irregularity  of 
the  pupils,  optic  neuritis,  and  other  eye  symptoms,  and  its  comparatively 
slow  progress,  are  characteristic  features.  The  diagnosis  is  based  upon 
examination  of  the  fluid  obtained  by  lumbar  puncture. 

Inflammation  of  the  Dural  Sinuses. — This  is  rarely  primary,  i.  e., 
incident  to  direct  infection  of  a  thrombosed  vessel  through  a  fracture. 
It  is  usually  secondary  to  infection  of  the  orbit,  sphenoidal  or  ethmoidal 
sinuses,  or  the  tympanum  and  mastoid  cells. 


236  THE  HEAD,  FACE,   AND  NECK 

The  characteristic  features  of  infection  of  the  lateral  sinuses  are:  A 
history  of  chronic  ear  trouble,  the  sudden  onset  of  vomiting,  fever  (the 
latter  often  preceded  by  a  chill  and  headache),  marked  fluctuations  of 
temperature  and  recurrence  of  rigor  or  chills,  edema  and  tenderness, 
both  over  the  mastoid  and  in  the  neck  along  the  course  of  the  internal 
jugular  vein,  a  condition  of  venous  stasis  in  the  scalp  of  the  temporal 
and  occipital  regions,  tenderness  and  perhaps  edema  elicited  by  deep 
pressure  below  the  external  occipital  protuberance  and  posterior  to  the 
mastoid  process,  some  stiffness  of  the  neck  muscles,  and  often  optic 
neuritis.  Exceptionally  there  is  irritation  or  palsy  of  the  hypoglossal, 
glossopharyngeal,  and  spinal  accessory  nerves,  or  even  of  the  pneu- 
mogastric.  It  will  be  noted  that  the  symptoms  are  those  of  septicemia 
or  pyemia,  combined  with  those  of  meningeal  irritation.  Metastatic 
abscesses  are  likely  to  develop  early  in  the  lung. 

Thrombosis  (septic)  of  the  cavernous  sinus,  secondary  to  suppuration, 
of  the  orbit,  or  of  the  sphenoid  or  ethmoid  cells,  is  characterized  by 
the  sudden  onset  of  septic  symptoms,  as  in  the  case  of  thrombophlebitis 
of  the  lateral  sinus,  together  with  congestion  and  edema  of  the  retina, 
swelling  about  the  forehead  and  eyelids,  usually  exophthalmos,  and 
paralysis  of  the  third,  fourth,  and  the  ophthalmic  branch  of  the  fifth 
nerve. 

Infection  of  the  superior  longitudinal  sinus  is  secondary  to  traumatic 
infection  of  the  adjacent  tissues.  The  only  suggestive  localizing  sign 
which  it  might  give  would  be  a  tendency  to  nose-bleed,  and  edema  and 
venous  congestion  along  the  course  of  the  sinus. 

Abscess  of  the  Brain.— Abscess  of  the  brain  is  characterized  by 
a  preceding  history  of  middle  ear  disease  or  of  trauma,  particularly 
that  incident  to  penetrating  punctured  wounds.  Abscess  is  manifested 
by  headache,  which  may  be  unilateral,  mental  asthenia  and  irritability 
with  somnolence  and  stupor,  percussion  tenderness  at  times,  surface 
heat  as  shown  by  the  surface  thermometer,  a  normal  or  even  subnor- 
mal temperature,  with  occasional  slight  transitory  rises  associated  with 
a  slow,  sometimes  intermitting,  pulse;  rigors,  vomiting,  constipation, 
possibly  unequal  pupils,  and  occasionally  optic  neuritis.  If  the  abscess 
is  situated  in  the  psychomotor  centres,  or  so  near  as  to  affect  them, 
its  localization  is  made  possible. 

Post-traumatic  abscesses,  if  developing  within  a  few  days  of  injury, 
are  usually  completely  masked  by  the  associated  meningo-en cephalitis. 
Their  presence,  however,  might  be  suspected  were  clearly  marked  focal 
symptoms  to  develop  early.  If,  after  an  interval  of  weeks,  months,  or 
even  years,  pain  with  remissions,  mental  inaptitude,  irritability,  and 
torpor,  and  the  symptoms  just  detailed  were  to  develop,  the  possibility 
of  intracranial  abscess  should  be  considered. 

Abscess  secondary  to  middle  ear  disease  may  present,  if  cerebral,  in 
addition  to  the  symptoms  characteristic  of  intracerebral  abscesses  in 
general,  a  history  of  chronic  middle  ear  disease,  often  peripheral  facial 
palsy,  aphasia,  twitchings,  rigidity  or  palsy  of  the  arm  of  the  side 
opposite  to  the  lesion,  or  hemiplegia  or  hemianesthesia. 


THE  HEAD  237 

Such  an  abscess,  if  cerebellar,  might  be  marked  by  staggering  gait, 
vertigo,  and  obstinate  vomiting. 

An  abscess  may  develop  without  any  localizing  symptoms,  exception- 
ally without  the  general  symptoms  of  septic  absorption,  cerebral  irrita- 
tion, or  pressure,  until  by  rupturing  into  the  ventricles  it  suddenly  causes 
convulsions,  coma,  and  death,  or,  reaching  the  meninges,  sets  up  an 
acute  diffuse  meningo-encephalitis. 

Secondary  to  middle  ear  disease,  meningo-encephalitis,  sinus  throm- 
bosis, and  abscess  are  about  equally  common.  All  are  characterized 
by  similar  symptoms.  Moreover,  acute  inflammation  of  the  middle 
ear  or  mastoiditis  with  retention  of  pus  will  cause  fever,  rapid  pulse, 
severe  pain,  and  often  delirium,  with  symptoms  of  slight  meningeal 
irritation. 

A  differential  diagnosis  may  be  formulated  by  considering  that  meningo- 
encephalitis is  violent  in  onset  and  rapid  in  course,  and  is  evidenced 
by  high  fever,  rapid>  often  irregular,  pulse,  strabismus,  and  often  stiffness 
of  the  jaws  and  the  back  of  the  neck. 

Thrombosis  of  the  lateral  sinus  is  attended  with  marked  edema  and 
swelling  about  the  ear,  especially  behind  it,  and  sometimes  involving 
the  entire  head  on  the  aft'ected  side ;  it  may  exliibit  tenderness  and  indura- 
tion along  the  course  of  the  internal  jugular  vein  and  choked  disk.  The 
symptoms  shortly  become  profoundly  septic,  with  the  chills,  fever,  and 
sweats  of  this  condition,  and  the  rapid  pulse  and  metastatic  deposits 
occur  early.  Intracranial  abscess  is  characterized  by  a  slow  pulse, 
and  subnormal  or  but  little  above  normal  temperature,  by  dulled  men- 
tality, often  aphasia,  vertigo,  and  signs  of  irritation  or  compression  of 
cortical  motor  and  sensory  areas  in  the  brain. 

Acute  otitis  media  and  chronic  mastoiditis  with  retention  are  character- 
ized chiefly  by  pain  and  its  systemic  effect,  nor  is  there  the  appearance 
of  serious  illness  which  characterizes  the  intracranial  infections. 

When  it  is  impossible  to  distinguish  between  these  conditions,  and 
this  is  often  the  case,  since  two  or  more  are  commonly  associated,  the 
diagnosis  must  be  made  by  exploratory  operation  above  the  middle  of 
the  bony  meatus  (measured  vertically  from  Reid's  base  line,  i.  e.,  a  line 
passing  from  the  lower  orbital  margin  through  the  middle  of  the  bony 
meatus).  Through  this  opening  a  probe  may  be  passed  between  the 
dura  and  the  roof  of  the  tympanum;  by  enlarging  this  opening  upward 
and  backward  for  about  2  cm.,  access  to  the  temporosphenoidal  lobe 
is  facilitated. 

In  the  absence  of  extradural  or  subdural  pus,  or  pronounced  subdural 
serous  effusion,  the  substance  of  the  brain  is  explored  by  either  a  grooved 
director  or  an  aspirating  needle  with  a  canal  of  at  least  1  mm.  caliber,. 
The  hypodermic  syringe  is  inadequate,  since  the  thick  pus  of  cerebral 
abscesses  will  not  pass  through  its  fine  canal.  The  direction  of  explora- 
tion from  a  point  3  cm.  above  and  3  cm.  behind  the  bony  meatus  is 
downward,  forward,  and  inward. 

The  lateral  sinus  is  reached  by  a  trephine  opening  tangent,  in  its 
lower  periphery,  to  Reid's  base  line,  and  an  inch  (2.5  cm.)  behind  the 


238  THE  HEAD,  FACE,  AND  NECK 

middle  of  die  bony  meatus.  A  hypodermic  needle  thrust  into  the  sinus 
will  show  the  presence  or  absence  of  fluid  blood;  in  the  latter  case  the 
sinus  should  be  opened. 

The  cerebellum  is  reached  through  a  trephine  opening  tangent  to 
Reid's  base  line  in  its  upper  segment  and  placed  4  cm.  behind  the  middle 
of  the  bony  meatus.  The  direction  of  exploration  into  the  cerebellar 
substance  should  be  upward,  forward,  and  inward. 

From  neoplasm,  fungus  may  be  distinguished  by  its  direct,  almost 
immediate,  relation  to  trauma  or  suppuration  and  by  microscopic 
examination. 

Tumors  of  the  Scalp  and  Cranium. — Superficial  growths  which 
originate  in  the  skin  or  beneath  it,  and  move  with  the  scalp,  are  angioma, 
or  birthmark,  wart,  sebaceous  cyst  (may  become  adherent  from  inflam- 
mation), lipoma,  gumma,  epithelioma,  sarcoma,  fibroma,  keloid,  lymph- 
angioma, neurofibroma,  enchondroma,  and  osteoma. 

The  growths  not  moving  with  the  scalp  attached  to  the  bone  and  in 
their  early  development  of  dense  consistency  are  gumma,  exostosis, 
tuberculoma,  and  osteosarcoma.  Tumors  not  movable  over  the  peri- 
cranium and  fluctuating  from  the  first  are  subcranial  cephalhematoma; 
dermoid  cysts;  if  partly  or  wholly  reducible,  meningocele,  perforating 
tuberculous  abscess,  or  blood  cyst  communicating  with  a  sinus. 

Verruca. — Verrucae,  or  warts,  of  the  scalp  are  common  in  elderly  persons. 
They  are  usually  single,  exceptionally  they  are  multiple  and  confluent, 
and  a  large  area  of  the  scalp  may  be  covered  by  the  hypertrophied 
papillae.  From  their  position  these  warts  are  subject  to  recurring  irrita- 
tion, they  bleed  readily,  become  ulcerated,  and  are  frequently  the  starting 
points  for  epitheliomatous  degeneration.  Before  such  transformation 
they  cannot  well  be  mistaken  for  any  other  lesion. 

Angioma. — ^The  head  is  a  favorite  seat  for  vascular  tumors.  They 
are  usually  congenital,  though  the  lesion  may  be  so  slight  at  birth  as  to 
escape  notice.  They  are  characterized  by  red,  purple,  or  deep  brown 
discoloration  of  the  skin,  often  associated  with  a  growth  of  hair.  From 
them  sarcoma  may  develop,  and  lipoma  and  fibroma  sometimes  accom- 
pany them. 

In  its  slightest  form  the  angioma  appears  as  a  red  splash  upon  the 
skin.  ^Vhen  the  arteries  and  veins  participate  markedly  in  the  dilata- 
tion, a  soft,  depressible,  purple,  flat  or  rounded  tumor  is  formed,  usually 
in  the  frontal  and  temporal  regions  of  an  infant.  This  tumor  can  be 
emptied  by  pressure,  and  if,  after  it  is  emptied,  a  ring  is  pressed  firmly 
about  the  growth  the  blood  will  reaccumulate  very  slowly. 

In  the  deep  form  placed  beneath  the  temporal  aponeurosis  a  heman- 
gioma forms  a  soft,  sometimes  pulsating  tumor,  which  becomes  dis- 
tinctly larger  during  crying  efforts  and  on  placing  the  head  in  a 
dependent  position.  The  diagnosis  is  usually  dependent  upon  asso- 
ciated angiomatous  manifestations  in  the  skin.  Meningocele  is  not 
likely  to  be  found  in  the  temporal  region. 

Cirsoid  aneurysm,  commonly  an  affection  of  early  adult  life  and 
usually   affecting    the    temporal   and    parietal    regions,    forms    a    flat, 


THE  HEAD  239 

pulsating  tumor,  made  up  of  many  dilated  and  tortuous  arteries,  the 
course  of  which  can  be  both  seen  and  felt.  The  overlying  skin  is 
thickened  and  purplish  in  color. 

iVrterial  aneurysm,  usually  traumatic  and  rare  since  the  days  of 
phlebotomy,  is  marked  by  the  development  of  a  pulsating  tumor, 
usually  in  the  course  of  the  temporal  artery,  which  gives  thrill  and  inter- 
mittent bruit,  and  partly  or  completely  disappears  when  pressure  is 
made  in  the  arterial  trunk  proximal  to  the  tumor. 

Arteriovenous  aneurysm  develops  in  the  temporal  and  the  frontal 
region  as  a  flattened,  pulsatile  tumor  with  bosselated  surface  because  of 
the  dilated  veins.  Thrill,  expansile  pulsation,  and  constant  murmur, 
often  harsh  and  loud,  with  exacerbations  synchronous  with  the  systolic 
impulse,  are  present.  It  is  distinguished  from  cirsoid  aneurysm  by  its 
traumatic  origin,  the  absence  of  skin  pigmentation  or  alteration,  and  the 
fact  that  pressure  at  the  point  of  communication  between  artery  and  vein, 
stops  the  bruit  and  pulsation.    The  venous  dilatation  may  be  widespread. 

A  blood  tumor  communication  with  a  dural  sinus  forms  a  small, 
rounded,  soft,  or  fluctuating  tumor,  usually  in  the  course  of  the  superior, 
longitudinal  sinus.  It  is  chiefly  characterized  by  the  fact  that  it  is 
reducible,  and  is  made  tense  by  straining  efforts  or  a  dependent  posi- 
tion of  the  head.  Exceptionally  after  reduction  the  bony  opening  may 
be  felt.  The  tumor  may  be  congenital,  traumatic,  or  without  assignable 
cause.     It  gives  neither  pulsation  nor  bruit. 

Elephantiasis. — Elephantiasis  in  the  few  cases  observed  has  affected 
the  skin  of  the  scalp  in  the  occipital  region  forming  a  pendulous  flap 
of  coarse,  greatly  thickened,  indurated  skin. 

Fibroma. — Fibroma,  in  its  superficial  hard  form,  appears  as  keloid,  a 
dense,  smooth,  pink  or  white,  raised,  commonly  painless  induration 
about  a  scar,  distinctly  outlined,  throwing  out  claw-like  projections 
into  the  surrounding  healthy  skin.  In  its  soft  form  the  fibroma  forms 
an  infiltration  into  and  beneath  the  skin.  It  is  often  multiple,  involving 
not  only  the  scalp  but  other  parts  of  the  body.  The  tumors  may  be 
extensive,  forming  pendulous  flaps,  or  may  appear  as  small,  single,  or 
multiple  infiltrations. 

Neurofibroma  of  the  scalp  is  characterized  by  the  development  of  a 
soft,  nodular,  sometimes  very  extensive  tumor.  The  nerve  or  nerves 
affected  are  tortuous,  beaded,  and  tender.  This  is  particularly  marked 
about  the  periphery  of  the  swelling,  the  skin  and  subcutaneous  tissue 
being  greatly  thickened  about  the  centre.  The  skin  may  be  freely 
movable  over  the  neuromatous  nodules,  these  in  turn  being  movable 
over  the  scalp.  This  tumor  presents  the  appearance  of  a  thickened, 
hypertrophied,  sometimes  pigmented,  and  hirsute  flap  of  skin;  its  seat 
of  election  is  the  side  of  the  head. 

Fibrolymphangioma,  appearing  first  as  a  small  soft  infiltration  of  the 
occipital  region,  when  well  developed  becomes  more  or  less  pedunculated, 
presenting  a  vermiform  surface  suggesting  the  presence  of  dilated  and 
tortuous  vessels.  This  tumor  is  always  intimately  adherent  to  the  skin 
and  does  not  exhibit  the  nodulation  of  the  fibroneuromata. 


240 


THE  HEAD,  FACE,  AND  NECK 


Lipoma. — ^A  rare  scalp  tumor  shows  a  predilection  for  the  forehead 
just  external  to  the  upper  part  of  the  frontal  protuberance  at  the  part 
where  the  hat  brim  presses.  It  forms  a  soft,  rounded  tumor  which 
closely  resembles  a  sebaceous  cyst.  Lipomata,  probably  congenital 
in  origin,  may  grow  beneath  the  temporal  fascia,  forming  elastic  swell- 
ings which  may  reach  great  size.  These  growths  commonly  develop  in 
middle  life  (Chipault). 

Wens,  or  Sebaceous  Cysts. — These  are  characterized  by  the  develop- 
ment of  one  or  usually  many  raised,  rounded,  tense,  semifluctuating, 
non-inflammatory  tumors  of  varying  sizes,  from  5  cm.  to  10  cm.  in 
diameter,  adherent  to  the  skin  in  their   central  part,  and   sometimes 

Fig.  86 


Wens.     Many  years'  duration;  movable,  non-sensitive,  hard. 

exhibiting  the  dilated  aperture  of  a  duct  from  which  sebaceous  matter 
can  be  squeezed  out.  The  adhesion  to  the  skin  is  often  difficult  to 
detect  in  small  tumors  which  have  not  been  inflamed  or  exposed  to 
pressure.  Nor  can  the  duct  leading  to  the  accumulation  of  sebaceous 
matter  usually  be  found.  Most  tumors  grow  slowly.  When  they 
become  irritated  and  infected  the  symptoms  are  those  of  abscess.  After 
evacuation  of  pus  and  sebaceous  matter  there  is  often  left  a  sinus  or  an 
ulcerating  surface  with  indurated  borders  strongly  suggesting  gumma 
or  epithelioma.  Malignant  infiltration  may  take  its  starting  point  from 
an  inflamed  sebaceous  cyst.  These  cysts  are  commonest  in  women 
at  or  past  middle  life. 


THE  HEAD 


241 


Epithelioma,  or  Skin  Cancer. — Epithelioma,  commonly  beginning  as  a 
chronically  inflamed  wart,  patch  of  keratosis,  or  sebaceous  cyst,  is 
characterized  by  ulceration  which  is  persistent  and  slowly  (months, 
years)  progressive.  Young  people  are  not  entirely  exempt.  The  fore- 
head and  the  parietal  region  are  the  points  of  election.     The  lesion  may 


Fig.  87 


Epithelioma  of  scalp.  Chronic  sloughing  ulcer,  irregular  in  outline,  with  elevated  borders  and 
infiltrated  reddened  areola.  Si.x  months'  duration.  Second  point  of  ulceration  beginning  at  lower 
periphery  of  the  neoplasm. 

appear  as  a  punched-out  ulcer  which  has  destroyed  everything  in  its 
course,  even  the  bone,  unaccompanied  by  lymphatic  involvement,  and 
exhibiting  a  very  narrow  area  of  induration  about  its  purple,  ragged 
edges.  This  form,  the  rodent  ulcer,  is  slow,  lasting  for  years,  and  pro- 
ducing appalling  deformities. 

The  epitheliomata  characterized  by  pronounced  induration  and  by 
fungating  granulations  and  lymphatic  enlargements  are  rapidly  fatal. 
16 


242  THE  HEAD,  FACE,  AND  NECK 

Senile  epithelioma  may  begin  as  a  hard,  cutaneous  or  subcutaneous, 
vascular,  purplish  nodule. 

Persistent  scab  formation  and  induration  of  any  scalp  lesion  in  an 
elderly  person  should  always  suggest  epithelioma.  If  syphilis  can  be 
ruled  out,  the  diagnosis  should  be  made  immediately  by  wide  excision 
of  the  inflammatory  lesion  and  examination  with  the  microscope. 

The  cutaneous  and  subcutaneous  gummata,  in  both  their  formative 
and  ulcerative  stages,  may  resemble  the  infiltration  of  epithelioma. 
These  lesions  are,  however,  fairly  rapid  in  course  (weeks),  show  no 
peripheral  infiltration,  do  not  involve  lymphatic  glands,  are  painless, 
yield  to  specific  treatment,  and  are  associated  with  a  history  of  syphilis 
or  other  signs  of  the  disease. 

Tuberculosis  in  the  form  of  lupus  begins  in  early  life,  exhibits  multiple 
lesions,  no  induration,  no  lymphatic  enlargements,  is  less  deeply  destruc- 
tive, and  exhibits  the  peripheral  jelly-like  nodules. 

Osteoma  and  Chondroma. — Osteoma  and  chondroma  have  both  been 
observed  free  from  the  bones  of  the  skull  and  movable  with  the  scalp. 
The  nodulated  hardness  of  these  tumors  would  suggest  their  structure. 

Usually  these  tumors  are  fixed  to  the  cranium,  exhibiting  hard,  flat 
or  rounded,  single  or  multiple,  sessile  or  pedunculated  outgrowths,  often 
post-traumatic. 

They  may  be  external  or  internal  or  may  project  from  both  surfaces 
of  the  cranial  bones.  The  internal  osteomata  are,  since  they  rarely 
reach  large  size,  usually  symptomless. 

Sarcoma. — Sarcoma  of  the  scalp  is  characterized  by  the  rapid  develop- 
ment of  a  soft,  vascular,  semifluctuating  tumor.  The  growth  may  be 
metastatic,  extend  from  the  dura  through  perforated  bone,  or  may 
originate  in  an  angioma  of  the  skin  or  beneath  it.  In  the  latter  case 
it  may  be  pigmented  and  smaller  tumors  may  form  about  the  central 
one.  The  superficial  sarcomata  erode  the  bone,  forming  a  direct  com- 
munication with  the  interior  of  the  skull.     They  are  often  pulsatile. 

Sarcoma  of  the  cranial  bones,  frequently  post-traumatic,  may  at  first 
be  hard  and  nodular;  later,  in  the  myelogenic  forms  as  the  covering 
shell  of  bone  is  thinned,  there  is  crackling  on  pressure,  as  of  a  broken 
eggshell.  There  is  at  times  severe  pain.  The  major  symptom  is  tumor 
which  in  the  beginning  exactly  simulates  gumma  and  grows  about  as 
rapidly.  The  diagnosis  should  be  made  by  removal  and  examination 
if  syphilis  can  be  excluded.  The  rapid  growth  of  an  osteoma  should 
suggest  sarcomatous  degeneration. 

Of  the  soft,  fixed,  irreducible  tumors  of  the  cranium,  sebaceous  cyst, 
which  has  become  adherent  from  inflammation  and  erosion,  is  recognized 
by  the  history  of  its  development  and  its  long  standing.  Gummata 
sometimes  form  flat  or  rounded,  boggy,  painful  swellings  on  the  frontal 
and  parietal  regions,  accompanied  by  severe  pain.  The  diagnosis  is 
based  on  the  history  and  the  therapeutic  test.  Pain  and  tenderness  are 
well  marked. 

Encapsulated,  translucent  serous  cysts,  sometimes  found  in  the  occipital 
region,  are  probably  the  remains  of  a  true  meningocele. 


THE  HEAD  243 

Cystic  sarcoma  which  has  perforated  the  cranium  from  without 
inward  is  characterized  by  its  large  size,  the  dilated  veins  overlying 
and  surrounding  it.  Perforating  sarcomas  from  the  dura  in  their  later 
stages  .are  neither  pulsatile  nor  reducible. 

Cephalocele. — Cephalocele,  or  projections  of  the  brain  and  its  mem- 
branes through  congenital  bone  defects  of  the  skull,  are  usually  flaccid, 
sometimes  tense  tumors,  springing  from  the  midline  in  the  frontal 
occipital  region.  When  not  obscured  by  overlying  lipomatous  or  angio- 
matous growths,  these  protrusions  form  smooth,  rounded,  sometimes 
large,  or  fluctuating  reducible  tumors  which  become  tense  when  the 
child  cries. 

Encephalocele  (rare)  made  up  of  brain  substance  without  cystic 
formation  usually  occupies  the  frontal  region  and  forms  a  soft  elastic 
swelling  which  is  generally  pulsatile,  partly  reducible,  causing  pressure 
symptoms  when  this  is  attempted,  and  becomes  larger  on  straining 
efforts.     This  growth  is  not  translucent. 

Encephalocystocele,  the  usual  form  of  tumor,  in  which  there  is  brain 
substance  and  within  this  a  cavity  containing  cerebrospinal  fluid,  may 
be  small  or  large.  The  occipital  region  is  the  seat  of  preference.  The 
brain  substance  may  be  so  attenuated  in  the  walls  of  the  lumen  that 
translucency  is  obvious. 

Cephalocele  may  project  into  the  orbit,  nose,  pharynx,  or  mouth, 
and  has  been  mistaken  for  nasal  or  pharyngeal  polyp. 

True  meningocele  is  rare. 

Angioma,  if  placed  in  the  midline,  may,  because  of  its  apparent 
reducibihty  by  pressure  and  its  change  in  size  and  lumen  incident  to 
crying  or  straining,  simulate  cephalocele. 

Dermoid  Cysts. — A  congenital  tumor  which  may  develop  in  adult  life 
is  evidenced  by  the  growth  of  a  rounded  tense  tumor  which  exhibits 
a  predilection  for  the  upper  midforehead  and  outer  orbital  regions. 
It  is  adherent  to  the  bone  below,  and  in  the  latter  there  may  be  felt 
a  depression.  This  tumor  closely  resembles  a  sebaceous  cyst.  Its 
adhesion  to  the  skull  and  its  development  in  infancy  and  early  child- 
hood would  aid  in  forming  a  diagnosis.  An  intracranial  dermoid  would 
give  only  the  symptoms  of  local  or  general  pressure. 

Pneumocele  of  the  Scalp. — Pneumocele  of  the  scalp  is  characterized 
by  resonance  on  percussion  and  reducibihty  by  pressure.  It  may 
develop  on  the  frontal  or  the  supramastoid  region,  and  is  due  to  a  trau- 
matic or  pathological  opening  into  the  frontal  or  the  mastoid  cells. 
After  these  cysts  are  emptied  they  can  again  be  filled  by  holding  the 
nostrils  and  attempting  to  blow  through  the  nose.  They  may  gradually 
attain  large  dimensions  and  may  be  subaponeurotic  or  subperiosteal. 

Hydrocephalus. — Hydrocephalus  may  be  congenital  or  acquired.  In 
its  congenital  form,  frequently  associated  with  syphilis,  rickets,  cephalo- 
cele, or  spina  bifida,  it  is  characterized  by  a  disproportion  in  size 
between  the  cranium  and  face  incident  to  overdistension  of  the  ventricles 
with  fluid  and  consequent  yielding  of  the  cranial  walls.  The  sutures 
and  fontanelles  are  thus  prevented  from  closing.     The  soft,  bulging, 


244 


THE  HEAD,  FACE,   AND  NECK 


heavy  head,  with  its  enlarged  veins;  the  small  face,  raised  eyebrows, 
and  projecting  displaced  eyeballs  are  characteristic  at  a  glance. 

x\cquired  hydrocephalus,  symptomatic  of  obstruction  from  inflamma- 
tion or  tumor,  if  it  develops  after  the  period  when  the  skull  is  closed,  will 
be  characterized  by  the  stupor  of  cerebral  pressure,  often  by  muscular 
rigidity  expressed  in  the  extremities.  The  condition  is  usually  over- 
shadowed by  the  symptoms  of  the  causative  lesion.  The  diagnosis  may 
be  made  by  ventricular  puncture. 

Microcephalus. — Microcephalus,  or  abnormally  small  head,  secondary 
to  congenital  malformation  of  the  brain,  if  pronounced,  is  obvious  at  a 
glance.  Normal  variations  are  so  great  that  it  is  often  difficult  to  decide 
when  the  pathological  has  been  reached.  Surgical  enthusiasm  and 
belief  in  the  efficacy  of  operative  measures  has  no  doubt  led  to  the  detec- 
tion of  a  microcephalus  which  would  otherwise  not  have  been  observed. 
Exceptionally  early  closure  of  the  sutures  is  noticed.  These  cases  are 
characterized  by  persistence  of  the  infantile  state. 


THE  FACE. 


Malformations. — Harelip,  partial,  complete,  or  double,  often  asso- 
ciated with  partial  or  complete  palatal  cleft,  is  the  common  malforma- 
tion. It  is  sometimes  associated  with  symmetrical  tumors  placed  near 
the  midline  of  the  lower  lip  and  discharging  each  from  its  duct  a  salivary 
fluid. 


Fig.  88 


Single  harelip.     Deformity  of  nose  in  excess  of  average  case.     (University  Hospital.) 

Other  congenital  deformities,  such  as  lateral  or  mesial  nasal  cleft, 
oblique  facial  cleft,  clefts  in  the  cheeks,  or  median  cleft  of  the  lower  lip 
or  under  jaw,  are  extremely  rare. 


PLATE  XIII 


Lupus    Erythematosus.     (Hartzell.) 


THE  FACE 


245 


Fibrocartilaginous  skin  tabs  upon  the  cheeks  and  neck  near  the  ear 
are  not  uncommon. 

Contusion.  —  The  rapid  swelHng  following  contusion  may  cause 
underlying  fracture  of  the  bones  of  the  face  to  be  overlooked.  The 
zygoma,  the  orbital  ridge,  the  nasal  bones,  and  the  maxillffi  should  be 
carefully  palpated  when  injury  is  so  applied  as  to  endanger  these 
structures.  Emphysema  is  diagnostic  of  a  fracture  of  the  nose  or  of 
the  walls  of  the  nasal  sinuses. 

Fracture  of  the  malar  bone  is  occasionally  characterized  by  a  depression 
of  the  zygoma.  The  deformity  may  be  elicited  by  careful  palpation, 
even  when  there  is  an  extensive  overlying  blood  effusion.  This  is  also 
true  of  fracture  which  has  driven  in  the  anterior  antral  wall. 

Fig.  89 


Cleft  palate  and  harelip. 

Skin  Lesions. — The  skin  of  the  face  is  subject  to  a  multiplicity  of 
lesions  of  which  the  commonest  are  acne,  comedo,  milium,  seborrhea, 
the  various  manifestations  of  the  exanthemata,  erythema,  herpes,  urti- 
caria, syphilides,  impetigo  contagiosa,  dermatitis  venenata  and  medi- 
camentosa, erysipelas,  eczema,  recurrent  hydroa  puerorum,  xanthoma, 
tinea,  angioma,  lymphangioma,  fibroma,  lupus,  and  epithelioma. 

Acute  Inflammatory  Affections  of  the  Face. — Furuncle. — Furuncle, 
though  it  may  occur  in  any  part  of  the  face,  has  its  seat  of  preference 
in  the  upper  lip  and  the  inner  aspect  of  the  nasal  orifice.  It  may  be 
characterized  by  edema,  pain,  tenderness,  induration,  and  constitutional 
symptoms  of  infection  much  more  pronounced  than  are  caused  by  the 
lesion  in  other  parts  of  the  body. 

Carbuncle. — Carbuncle,  a  conglomeration  of  furuncles,  is  accompanied 
by  pronounced  local  and  constitutional  symptoms  of  inflammation.  The 
redness  and  edematous  swelling  may  be  so  widespread  as  to  suggest 
erysipelas.  It  occasionally  terminates  fatally  in  a  few  days  by  septic 
thrombosis  and  meningitis,  extending  from  the  orbit  to  the  cavernous 


246  THE  HEAD,  FACE,   AND  NECK 

sinus.  Dilatation  of  the  veins  about  the  orbit,  exophthalmos,  chemosis, 
and  profound  sepsis  out  of  proportion  to  the  local  lesion  would  suggest 
such  an  extension.  Even  in  favorable  cases  there  may  be  extensive 
tissue  necrosis. 

Maligant  Pustule. — Malignant  pustule  is  characterized  by  a  burning 
nodule,  surmounted  by  a  discolored  vesicle  which  bursts  and  forms  a 
brown  scab,  about  which  secondary  vesicles  form  and  rupture,  leaving 
a  surface  of  ulceration.  The  swelling  spreads  rapidly,  quickly  involving 
the  associated  lymph  glands,  and  in  one  or  two  days  constitutional 
symptoms  of  severe  septic  infection  develop.  The  diagnosis  of  anthrax 
is  based  upon  the  presence  of  the  vesicles  and  their  dissemination  and 
the  finding  of  the  characteristic  bacillus  (p.  76). 

Glanders. — Glanders,  usually  primary  in  the  mucous  membrane  of  the 
nose  or  throat,  may  attack  an  abrasion  or  wound  of  the  skin  of  the  face, 
running  through  an  acute  or  chronic  course.  It  forms  characteristic 
ulcerating  nodules,  and  is  diagnosticated  by  the  detection  of  the  bacillus 
mallei  (p.  77). 

Erysipelas. — Erysipelas  commonly  begins  in  a  surface  break  about  the 
opening  of  the  nostrils  or  the  lips  and  sweeps  over  the  face  to  the  hair 
line  and  often  beyond.  It  is  usually  superficial  in  type  and  accompanied 
by  great  swelling,  redness,  slight  vesication,  glandular  involvement,  and 
marked  constitutional  symptoms  of  sepsis.  It  is  often  inaugurated  by 
vomiting.  It  lasts  about  a  week,  but  may  clear  up  in  a  day  or  not  for  a 
month.  Its  peripheral,  rapidly  extending,  raised  border,  representing  the 
seat  of  greatest  inflammation  is  characteristic  (p.  75). 

Noma. — Noma  is  characterized  by  the  development  of  an  acute  gan- 
grenous process,  beginning  as  a  dirty  white  patch  on  the  gums  or  inner 
surface  of  the  cheek  and  rapidly  (hours  or  days)  causing  extensive 
destruction  of  both  bone  and  soft  parts.  A  streptothrix  is  constantly 
found.  It  develops  in  anemic  children  after  measles  and  scarlet  fever, 
rarely  in  sucklings  or  adults.  It  is  characterized  in  its  early  develop- 
ment by  extensive  infiltration,  an  apparently  superficial  erosion  of  the 
inside  of  the  buccal  mucous  membrane  being  attended  with  a  thick 
hardness  of  the  cheek  and  a  dusky  discoloration  of  the  overlying  skin. 

Acute  Lymphadenitis. — Acute  lymphadenitis,  suppurative  in  type,  not 
infrequently  develops  in  the  gland  lying  in  the  front  of  the  ear,  in  one  or 
more  of  the  group  lying  in  the  cheek,  or  in  that  placed  on  the  outer  border 
of  the  body  of  the  jaw,  forming  an  abscess  much  like  a  furuncle,  except- 
ing that  it  is  preceded  by  a  hard,  tender  tumor  formed  by  the  inflamed 
gland,  causes  a  more  extensive  swelling  and  redness,  and  the  involve- 
ment of  the  skin  is  secondary. 

Angioneurotic  Edema. — Angioneurotic  edema,  usually  mistaken  for  the 
bite  or  sting  of  an  insect,  is  common  on  the  face,  particularly  in  the 
region  of  the  upper  lip,  is  marked  by  a  sudden  swelling,  commonly 
noticed  on  rising  in  the  morning,  accompanied  by  some  heat  and  burning 
pain.  It  subsides  in  a  few  hours  or  at  most  one  or  two  days.  The 
diagnosis  is  based  upon  the  sudden,  causeless  onset,  its  transitory  nature, 
and  the  very  slight  accompanying  inflammatory  phenomena. 


PLATE  XrV 


Lymphatics  and  Lymph  Nodes  of  the  Face. 


THE  FACE 


247 


Acute  swelling  of  the  face  may  be  due  to  inflammation  of  the  under- 
lying bones  or  their  cavities.  Osteomyelitis  of  the  jaws  incident  to 
carious  teeth,  or  occurring  as  a  local  expression  of  general  infection  fp. 
284)  or  inflammation  of  the  maxillary  or  frontal  sinuses,  is  the  common 
cause  of  this  secondary  swelling. 

Chronic  Ulceration  of  the  Face. — Tuberculosis. — Lupus  has  for  the 
seat  of  predilection  the  face.  It  begins  in  early  childhood,  or  at  least 
before  puberty.  It  is  often  associated  with  other  manifestations  of 
tuberculosis. 

The  disease  first  appears  in  the  form  of  small  brownish  nodides 
about  the  nose,  cheeks,  chin  or  lips,  or  forehead.  It  is  extremely  chronic 
(years),  and  extends  by  slow  destructive  ulceration,  cicatrization  going 
on  at  the  same  time.  There  is  a  non-ulcerative  form  characterized  by 
the  development  of  scar  tissue.  The  ulcerative  form  reaches  the  under- 
lying bony  or  cartilaginous  framework,  causing  deforming  cicatrices. 
It  commonly  spreads  to  the  mucous  membrane.  The  lymph  glands 
are  often  involved.     The  scar  tissue  is  subject  to  malignant  degeneration. 

In  certain  proliferating  or  de- 
structive forms  of  lupus,  the  Fig.  90 
lesions  may  closely  resemble  car- 
cinoma or  gumma.  The  history 
of  the  case,  its  extremely  slow 
course,  and  the  finding  of  the 
brownish  pinhead-sized  nodules 
will  aid  in  making  the  diagnosis. 

Tuberculous  Sinus.  —  Tubercu- 
lous sinus  may  form  on  the  face 
as  the  result  of  the  breaking- 
down  of  a  lymph  node  or  sec- 
ondary to  involvement  of  the 
facial  bones.  The  gland  in  front 
of  the  ear  is  the  one  which  com- 
monly suppurates.  Its  painless, 
non  -  inflammatory  enlargement 
precedes  softening,  and  is  usually 
accompanied  by  characteristic  in- 
duration of  the  submaxillary 
group.  The  second  common  seat 
of  sinus  formation  is  in  the  mid- 
dle of  the  cheek,  or  lower  down  over  the  body  of  the  jaw  secondary  to 
tuberculous  caries  of  the  bone,  commonly  found  at  the  outer  border 
of  the  orbit.  A  painless,  fluctuating  swelling  forms.  On  opening  this 
the  characteristic  cheesy  pus  is  discharged  and  necrosed  bone  can  be  felt. 

Chancre. — Chancre,  commonest  on  the  upper  lip,  may  be  found  on 
any  part  of  the  face,  is  characterized  by  its  comparatively  rapid  and 
relentless  development  (one  to  three  weeks),  the  absence  of  acute  inflam- 
matory symptoms,  induration,  and  the  early  and  pronounced  enlarge- 
ment of  the  associated  lymph  glands.     It  is  often  accompanied,  especially 


Tuberculous  sinus  of  cheek  preceded  by  indura- 
tion and  softening  of  mouth  gland. 


248 


THE  HEAD,  FACE,  AND  NECK 


on  the  lips,  by  pronounced  edema,  and  may  reach  a  size  much  larger 
than  is  characteristic  of  it  when  it  develops  upon  the  genitalia.  This 
is  particularly  true  of  chancre  of  the  cheek.  It  so  closely  resembles 
epithelioma  that  it  has  more  than  once  been  excised  on  the  basis  of 
this  diagnosis.  However,  it  attains  a  size  and  development  in  two 
weeks  not  reached  by  the  epithelioma  in  as  many  months. 


Fig.  91 


Chancre  of  cheek.     Duration,  weeks.     Painless,  indurated,  marked  enlargement  of  submaxillary 
glands.     Healed  with  very  slight  scar.     (Hartzell.) 


Papular  and  pustular  syphilides,  especially  when  they  occur  about 
the  nose  and  lips,  may  closely  resemble  lupus,  but  are  characterized  by 
their  much  more  rapid  development  associated  with  the  history  of 
syphilis  and  the  effect  of  constitutional  treatment. 

The  lesions  of  hereditary  syphilis  are  more  difficult  to  differentiate; 
their  destructive  effect  is  more  manifest  upon  the  bones  of  the  nose  than 
are  those  of  lupus. 

Gummata  of  the  Face. — Gumma  of  the  face  is  characterized  by  pain- 
less infiltration,  which,  untreated,  breaks  down  rapidly  (weeks),  forming 
rounded,  punched-out,  non-indurated  ulcers,  unaccompanied  by  glandu- 


Fig.  92 


Syphilitic   necrosis  of  the  bones  and  cartilages  of  the  nose.     Gumma  of  forehead  (frontal  bones) 
and  of  chin  (skin  and  subcutaneous  tissues). 

Fig.  93 


Circinate  syphilide.     (Hartzell.) 


250 


THE  HEAD,  FACE,   AND  NECK 


lar  enlargement.  They  occur  about  the  nose,  hps,  and  forehead,  and  by 
confluence  may  produce  extensive  destruction  of  both  soft  parts  and  the 
underlying  bone  and  cartilage.  They  are  distinguished  from  carcinoma 
by  the  history  of  syphilis  where  this  is  obtainable,  their  rapid  destructive 
course,  absence  of  induration,  and  absence  of  glandular  involvement. 
Gumma  causes  in  weeks,  exceptionally  in  days  in  the  hyperacute  form, 
destruction  which  epithelioma  may  not  accomplish  for  months  or  years. 
Actinomycosis. — ^Actinomycosis  of  the  face  is  usually  secondary  to 
infection  of  the  jaw.  It  is  often  associated  with  the  inflammation 
incident  to  a  carious  tooth.  As  elsewhere,  it  is  characterized  by  extensive 
induration  and  the  development  of  one  or  more  sinuses  (p.  76). 


Fig.  94 


Epithelioma.     Duration,  years.     No  glandular  involvement.     (Hartzell.) 

Epithelioma. — Epithelioma,  commonest  on  the  lower  lip  of  middle- 
aged  and  old  men,  usually  begins  in  a  spot  of  leukoplakia  about  the  lips 
or  in  pigmentations,  seborrheic  scales,  patches  of  keratosis,  or  warty 
growths  about  the  face. 

The  flat  form  (rodent  ulcer),  particularly  common  about  the  fore- 
head, temple,  and  nose,  forms  at  first  a  crust  beneath  which  lies  a  super- 
ficial ulcer  which  exhibits  a  cicatricial  tendency,  drawing  the  skin  into 
fine  radiating  wrinkles.  The  growth  may  remain  small,  superficial, 
and  stationary  for  many  years,  or  may  gradually  extend  in  all  directions. 


THE  FACE 


251 


involving  not  only  the  soft  parts,  but  the  bones  beneath,  producing 
extensive  destruction.     The  glands  are  not  involved. 

The  fungating  form,  common  about  the  lower  lip,  begins  as  an  indura- 
tion or  as  a  persistent   crusted   ulcer  which  extends  in  all  directions 
(months),  is  fungating,  infiltra- 
ting,   and    destructive,    and    is  fig.  95 
attended  by  early  gland  involve-                          ,^-3.*:--^ 
ment. 

The  diagnosis  of  cancer  of  the 
face  is  based  upon  the  presence 
of  a  persistent  or  recurring  ul- 
ceration which  is  neither  syphi- 
litic nor  tuberculous.  It  should 
be  formulated  while  the  ulcer  is 
still  small  by  excision  under  local 
anesthesia  and  microscopic  ex- 
amination. The  fully  developed 
lesion  can  be  recognized  across 
a  public  square,  but  the  diag- 
nosis is  no  longer  serviceable. 

Affections  Characterized  by 
Tumor  of  the  Soft  Parts  with- 
out Inflammatory  Phenomena. 
— Lipoma . — Lipoma  (rare) ,  wh  e  n 
subcutaneous,  exhibits  the  char- 
acteristic features  of  this  growth. 
Exceptionally,  it  grows  from  the 
pad  of  fat  lying  along  the  ante- 
rior border  of  the  masseter  mus- 
cle, forming  an  obscurely  fluc- 
tuating tumor  projecting  either  externally  or  within  the  mouth.  Diag- 
nosis will  be  suggested  by  the  extremely  slow  growth,  but  must  be  made 
by  incision. 

Fibroma. — Fibroma  is  often  congenital,  forming  flat,  wart-like  indura- 
tions, associated  with  pigmentation,  capillary  dilatation,  and  local  growth 
of  hair.  These  growths  may  slowly  increase,  forming  in  the  course  of 
years  pendulous  and  deforming  flaps.  The  plexiform  neurofibroma 
(congenital)  involves  the  skin  and  underlying  tissues  in  a  highly  character- 
istic nodular  growth. 

Hemangioma. — Hemangioma,  present  at  birth,  affecting  by  preference 
the  faces  of  girl  babies,  in  its  capillary  form  appears  as  a  red  blotch,  made 
more  prominent  by  crying,  often  associated  with  pigmentation  and  over- 
growth of  hair.  Its  growth  may  be  commensurate  with  the  general 
increase  in  size  of  the  body  or  it  may  extend  with  great  rapidity. 

Cavernous  hemangioma  forms  a  typical,  soft,  ill-defined,  dark  bluish 
tumor  which  may  be  reduced  by  pressure  and  which  increases  in  size 
from  cephalic  congestion.  This  growth  is  commonly  associated  with 
diffuse  fibroma,  and  may  cause  great  deformity.  When  placed  beneath 
the  temporal  or  the  occipitofrontal  fascia  it  may  simulate  meningocele. 


Epithelioma.     (Von  Bergmann's  clinic.) 


252 


THE  HEAD,  FACE,  AND  NECK 


Racemose  angioma  (rare)  exhibits  pulsation  and  dilated  and  tortuous 
bloodvessels. 

Lymphangioma. — Lymphangioma  forms  diffuse,  pasty  infiltrations 
covered  by  normally  colored  skin,  usually  congenital,  sometimes  cystic. 
This  dilatation  of  lymph  vessels,  often  associated  with  hemangioma  and 
fibrous  infiltration,  is  the  common  cause  of  macroglossia  and  macrocheilia. 

Sarcoma. — Sarcoma  of  the  skin  and  underlying  soft  tissues  of  the  face 
is  marked  by  its  rapid  growth.  Congenital  multiple  forms  have  been 
described.  The  orbit  is  the  common  seat,  and  it  is  distinguished  by 
its  rapid  growth  and  prompt  metastasis. 


Fig. 

96 

1 

t^ 

1 

>gmm 

'^^^^^^p 

li»'?^H 

9flMiiH^^I 

mtm 

^Bm 

^^^^H 

^^Hk^ 

r 

.^ip^ 

%Jt 

Tricho-epithelioma.     Benign  cystic  epitlielioma.     (Hartzell.) 

Diagnosis  should  be  based  upon  the  excision  and  examination  of  an 
apparently  causeless  inflammation  or  enlargement  of  a  mole  or  a  pig- 
mented spot,  or  the  appearance  of  a  tumor  not  obviously  benign. 

Sebaceous  Cyst. — Sebaceous  cyst,  comparatively  rare  in  the  face, 
forms  a  small,  hard,  shining,  round  growth  in  the  skin,  often  with  a 
central  aperture.  It  may  become  acutely  inflamed  or  undergo  calcifi- 
cation or  malignant  degeneration. 

Dermoid. — Dermoid,  usually  at  the  upper  outer  quadrant  of  the  orbit, 
forms  a  hard,  round  tumor  beneath  the  skin  and  unattached  to  it.  It 
indents  the  bone,  and  at  times  projects  through  this  structure  into  the 
orbit.     When  placed  on  the  bridge  of  the  nose  dermoid  grows  downward 


THE  EAR  253 

beneath  the  nasal  bone,  displacing  the  cartilage.  It  is  distinguished 
from  sebaceous  cyst  by  its  deeper  attachment,  its  position,  and,  when 
ulceration  takes  place,  by  the  discharge  of  hair.  Differential  diagnosis 
cannot  always  be  made. 

Echinococcus  and  cysticercus  cysts  (rare)  developing  on  the  face  may 
be  diagnosticated  as  such  only  by  associated  lesions  or  by  excision. 

Cutaneous  horns  are  recognized  on  sight. 

Adenomata. — Adenomata  of  the  sweat  and  sebaceous  glands  occurring 
in  old  people  cause  nodular  infiltration,  particularly  near  the  angle  of 
the  eye.  These  superficially  ulcerating  may  resemble  beginning  epithe- 
lioma.    Diagnosis  can  be  made  only  by  excision. 

Benign  cystic  epithelioma,  usually  appearing  before  puberty,  form 
hard,  indolent  tumors,  exhibiting  little  tendency  to  ulceration.  The 
diagnosis  is  based  upon  the  clinical  course  and  microscopic  examin- 
ation. 

Facial  Neuralgia. — Facial  neuralgia  may  be  due  to  toxic  conditions 
such  as  those  incident  to  gout  and  rheumatism,  may  be  a  local  expression 
of  a  general  neuropathy,  such  as  tabes,  may  be  due  to  neuritis,  or  may 
be  secondary  to  local  causes  such  as  carious  teeth,  otitis  media,  eye 
defects,  inflammation  of  the  maxillary  or  frontal  sinus,  or  the  pressure 
of  growths. 

Trifacial  neuralgia  independent  of  these  causes  is  epileptiform  in 
its  manifestations.  It  is  nearly  always  unilateral,  usually  spares  the 
first  division  of  the  nerve,  though  radiations  of  pain  may  take  place 
to  this,  and  is  often  accompanied  by  slight  spasm  of  the  muscles  of 
the  neck  and  face.  The  disease  is  characterized  by  recurring  violent 
attacks  of  pain,  sometimes  preceded  by  an  aura,  often  sudden  in  onset, 
accompanied  by  reddening  of  the  skin  of  the  affected  side,  perspiration, 
and  hypersecretion  of  saliva  and  tears.  Between  the  paroxysms,  which 
may  be  brought  on  by  eating,  talking,  touching  of  sensitive  points,  there 
are  intervals  of  complete  relief.  The  affection  attacks  by  preference 
middle-aged  men.  The  diagnosis  is  suggested  by  the  severity  of  the 
symptoms  and  the  persistent  recurrence.  Hysteria  must  be  excluded  and 
from  the  therapeutic  standpoint  the  epileptiform  attacks,  which  are 
cured  only  by  formidable  operations,  must  be  distinguished  from  those 
due  to  a  peripheral  source  of  irritation. 


THE  EAR. 

The  meatus  and  drumhead  of  the  ear  are  examined  by  means  of  a 
conical  speculum,  light  being  furnished  by  a  head  mirror  provided 
with  a  central  aperture.  This  examination  is  facilitated  by  drawing  the 
pinna  upward  and  outward,  since  thus  the  meatus  is  straightened. 
The  drumhead  lies  at  about  the  depth  of  one  inch  in  the  adult. 

The  condition  of  the  Eustachian  tube  as  to  its  perviousness  is  deter- 
mined either  by  inflating  through  the  nose  while  the  patient  is  swallowing, 


254  THE  HEAD,  FACE,  AND  NECK 

or,  more  readily,  though  less  accurately,  by  directing  him  to  take  a 
deep  inspiration,  close  the  mouth  and  nose  with  the  hand,  and  endeavor 
to  blow  out  through  both  at  the  same  time.  This,  if  the  Eustachian 
tube  be  open,  will  cause  a  sense  of  fulness  in  the  ears. 

Hearing  can  be  roughly  tested  by  the  watch,  the  patient  being  directed 
to  close  his  eyes  during  this  test.  If  impaired,  the  question  as  to  whether 
the  deafness  be  due  to  abnormality  in  the  conductive  or  the  receptive 
apparatus  may  be  determined  by  means  of  a  tuning  fork.  If  this, 
while  vibrating,  have  its  handle  pressed  firmly  upon  the  forehead,  it 
will  be  heard  most  distinctly  in  the  ear  in  which  the  conductive  apparatus 
is  deficient.  In  the  normal  ear  the  tuning  fork  should  be  heard  by  air 
conduction  after  the  bone  conduction  has  ceased  to  convey  impression. 

The  symptoms  of  surgical  affections  of  the  ear  are  pain,  alteration  in 
the  sense  of  hearing,  and  discharge,  supplemented  in  the  case  of  acute 
inflammation  by  the  local  and  general  symptoms  of  this  condition. 

Malformations. — Congenital  Deformities  of  the  Auricle. — These  are 
sufficiently  obvious  to  inspection.  The  tragus  may  depart  from  the 
normal  either  in  size  or  conformation.  Rolling  in  of  the  helix  and  flaring 
of  the  pinna  are  perhaps  the  two  commonest  congenital  deformities. 

Auricular  appendages  appearing  as  cartilaginous  skin  tabs  are  found 
on  a  line  with  the  tragus  and  the  angle  of  the  mouth.  The  external  ear 
may  be  entirely  absent. 

Congenital  fistula  from  which  there  is  an  oily  crusting  discharge 
has  been  observed  in  the  lobe  of  the  ear. 

Sebaceous  cysts,  angiomata,  and  fibromata  are  the  usual  benign  tumors. 
Of  the  malignant  ones,  epithelioma  is  comparatively  common  as  compared 
to  sarcoma. 

Wounds  of  the  Ear. —  Contusion. — Subcutaneous  blood  effusions, 
sometimes  without  history  of  trauma,  especially  frequent  among  the 
insane,  reach  their  greatest  size  on  the  posterior  outer  surface,  from  which 
they  are  rapidly  absorbed.  When  they  develop  on  the  inner  surface  they 
are  usually  associated  with  lesion  of  the  cartilage,  and,  if  the  ear  be 
subjected  to  repeated  trauma,  result  ultimately  in  a  thickening  which 
obliterates  the  normal  folds. 

Wounds  of  the  external  auditory  canal,  if  severe,  are  usually  compli- 
cated with  other  more  immediately  urgent  injuries. 

Fracture  of  the  bony  meatus  is  most  likely  to  be  caused  by  force  applied 
to  the  chin,  driving  the  condyle  upward  and  backward,  at  times  to  such  an 
extent  that  it  entirely  obliterates  the  canal  The  characteristic  symp- 
toms are  hemorrhage  from  the  ear,  pain  located  in  front  of  the  tragus 
and  greatly  aggravated  by  movement  of  the  jaw,  extreme  tenderness  at 
the  same  point,  and  subcutaneous  blood  effusion  or  actual  break  in  the 
skin  surface  of  the  meatus,  though  the  drum  membrane  is  likely  to  be 
intact,  nor  is  there  interference  with  hearing.  Trauma  sufficient  to 
cause  this  injury  is  usually  associated  with  concussion  of  the  brain  and 
often  with  basilar  fracture. 

Wounds  of  the  Tympanic  Membrane. — Wounds,  if  from  direct  violence, 
are  often  due  to  maladroit  efforts  at  extraction  of  foreign  bodies.     Violent 


THE  EAR  255 

air  concussion  may  produce  rupture  of  this  membrane.  It  is  some- 
times broken  by  insufflation,  by  a  violent  upward  pull  on  the  pinna,  as 
the  result  of  paroxysmal  cough,  or  from  excessive  air  pressure  or  the 
reverse. 

The  ruptures  from  indirect  violence  are  usually  incident  to  fracture 
of  the  base  of  the  brain;  exceptionally,  to  blows  on  the  head  in 
the  absence  of  fracture.  The  lesion  is  characterized  by  severe  but 
transitory  pain,  and  bleeding  from  the  ear,  at  times  very  free.  Dulness 
of  hearing  is,  as  a  rule,  but  slightly  marked.  Direct  examination  shows 
the  lesion,  the  lips  of  which  are  commonly  closed  by  a  small  blood  clot. 

Foreign  Bodies. — Often  found  in  children,  they  may  occasion  no 
symptoms  excepting  slight  interference  with  hearing.  As  a  reflex,  per- 
sistent cough  is  frequently  noted.  As  a  rule,  foreign  bodies  cause  acute 
inflammation  characterized  by  severe  pain,  swelling,  and  discharge 
of  pus.  Perforation  of  the  drumhead  and  suppuration  of  the  middle 
ear  are  likely  to  follow.    Diagnosis  is  based  upon  direct  examination. 

Concretions  of  cerumen  in  the  ear  are  characterized  simply  by  deafness 
which  comes  on  very  slowly;  at  times  with  great  rapidity.  This  is  not 
infrequently  associated  with  tinnitus  and  with  headache  and  vertigo 
which  closely  simulate  cerebral  affections. 

Acute  Tympanic  Congestion. — Acute  tympanic  congestion  incident 
to  exposure  to  cold,  moderate  trauma,  or  blocking  of  the  Eustachian  tube 
is  characterized  by  an  initial  pain  as  severe  as  that  which  ushers  in  otitis 
media,  and  differs  from  the  latter  only  in  the  fact  that  it  shortly  subsides 
under  almost  any  treatment.     It  is  common  in  children. 

Acute  Inflammation  of  the  Auditory  Meatus. — Acute  inflamma- 
tion of  the  auditory  meatus  may  be  circumscribed  or  diffuse.  Furuncle 
usually  begins  with  an  itching  sensation  in  the  ear,  followed  by  extreme 
pain,  greatly  aggravated  by  movement  of  the  jaws.  iJsually  the  swelling 
is  sufficient  to  entirely  close  the  meatus,  and  deafness  results.  The 
affection  is  likely  to  be  recurrent.  Its  diagnosis  is  based  upon  inspection. 
Diffuse  inflammation  of  the  auditory  meatus  is  frequent  in  infants  and 
a  common  accompaniment  of  cutting  the  teeth.  It  is  often  due  to 
traumatism  inflicted  by  ignorant  nurses  in  their  attempts  to  clean  the 
ear,  supplemented  by  infection  through  vomited  matter  or  sometimes 
through  milk  directly  injected.  It  is  at  times  a  complication  of  the 
exanthemata. 

The  characteristic  symptoms  are  severe  pain  aggravated  by  move- 
ments of  the  jaw,  great  tenderness  on  touching  the  external  ear,  swelling 
obliterating  the  depression  in  front  of  the  tragus,  slight  fever;  deafness 
and  tinnitus  only  when  the  meatus  is  swollen  shut.  The  skin  of  the 
meatus  is  reddened  and  swollen  and  the  tympanum  is  usually  inflamed. 
The  herpetic  form  is  characterized  by  vesicles.  In  two  or  three  days 
there  is  a  moderate  seropurulent  discharge,  sometimes  only  sufficient 
in  quantity  to  cause  crusting. 

According  to  the  particular  form  of  infection  the  duration  of  the  attack 
will  be  short  or  long.  Exceptionally  the  disease  involves  both  the 
tympanum  and  the  bony  canal  of  the  meatus. 


256  THE  HEAD,  FACE,   AND  NECK 

Distinction  from  furuncle  is  made  by  noting  that  the  entire  canal  is 
swollen.  The  immunity  of  the  middle  ear  can  be  determined  only  if 
the  swelling  be  of  such  moderate  degree  as  to  allow  the  direct  ex- 
amination of  the  drumhead.  When  complicated  by  osteoperiostitis  the 
distinction  from  middle  ear  disease  is  possible  only  on  operation. 

Chronic  external  otitis  is  usually  a  complication  of  chronic  otitis 
media.  There  is  often  superficial  caries  of  the  bone,  causing  pain, 
swelling,  and  tenderness  on  deep  pressure  and  the  development  of  fun- 
gous granulations.  Infection  is  sometimes  conveyed  to  the  temporo- 
maxillary  articulation.     Nor  is  extension  to  the  brain  uncommon. 

Tumors  of  the  Ear. —  Polyps  have  been  observed  in  the  external 
meatus.  Many  of  the  reported  cases  are,  however,  instances  of  exuber- 
ant granulations. 

Exostoses,  commonest  among  men,  may  be  single  or  multiple.  They 
grow  slowly,  causing  inconvenience  only  when  they  obliterate.  Diagnosis 
is  based  upon  the  density  of  the  tumor,  its  indolent  course,  the  absence 
ulceration  or  infiltration. 

Inflammation  of  the  Middle  Ear. — Common  in  infancy  and  youth, 
is  usually  secondary  to  nasopharyngeal  catarrh.  It  may  be  primitive 
in  the  tympanum  incident  to  traumatism.  It  is  a  common  sequel  of 
influenza,  typhoid  fever,  scarlet  fever,  measles,  indeed  of  all  the  exan- 
themata. It  may  be  catarrhal  or  frankly  suppurative.  In  the  latter 
case  there  is  commonly  inflammation  of  the  surrounding  bone. 

Acute  otitis  media  is  characterized  by  severe  pain  and  tension  referred 
to  the  ear,  which  is  tender  to  pressure  on  the  tragus;  pronounced  deaf- 
ness and  tinnitus.  These  symptoms  are  aggravated  by  swallowing 
motions,  coughing,  or  any  change  of  air  pressure  in  the  nasopharynx. 
In  the  suppurative  cases  these  symptoms  become  rapidly  and  progres- 
sively worse,  the  pain  being  unbearable  in  its  intensity  and  referred 
to  the  whole  side  of  the  head.  Constitutional  symptoms  of  sepsis 
develop,  together  with  those  of  meningeal  irritation. 

The  attack  sometimes  begins  with  headache,  vomiting,  vertigo,  and 
symptoms  strongly  suggesting  meningitis,  which  in  these  cases  is  doubt- 
less present.  Facial  palsy  may  develop  early.  The  tympanic  mem- 
brane, at  first  reddened,  becomes  dull  and  opaque,  nor,  excepting  in  the 
early  congestive  stage,  can  the  handle  of  the  malleus  be  seen.  Because 
of  the  accumulation  of  inflammatory  exudate  the  posterior  part  of  the 
membrane  is  bulged  outward. 

When  suppuration  takes  place,  there  are  tenderness  and  swelling  in 
the  mastoid  region  and  about  the  external  ear,  the  drumhead  ruptures, 
and  pus  and  blood  are  discharged  from  the  meatus.  This  is  followed 
by  immediate  subsidence  of  symptoms  and  usually  by  cure  with  restor- 
ation of  hearing  which  may  be  complete. 

If  pus  is  retained  because  of  thickened,  resisting  tympanic  membrane, 
acute  osteomyelitis  becomes  a  complicating  factor  with  meningitis, 
sinusitis,  thrombosis  or  brain  abscess,  profound  sepsis,  and  pronounced 
swelling  of  the  meatus  and  surrounding  soft  parts,  most  marked  in  the 
mastoid  region.     If  death  does  not  occur  from  sepsis  and  brain  complica- 


THE  EAR 


257 


tions,  there  will  be  fluctuation,  abscess  formation,  and  exposure  of 
dead  bone. 

Perforation  of  the  tympanic  membrane  is  rare  in  infants,  nor  can  they 
intelligently  voice  their  subjective  symptoms;  hence,  when  they  present 
symptoms  of  sepsis  and  brain  involvement,  the  ear  should  be  carefully 
examined  (Duplay).  This  rule  should  also  hold  good  in  case  of 
children  suffering  from  exanthemata,  typhoid  fever,  and  la  grippe  who 
exhibit  marked  symptoms  of  cerebral  irritation. 


Fio.  97 


Fig.  98 


Front  and  rear  view  of  external  swelling  in  otitis  media.      (Alderton.) 


Chronic  Suppurative  Otitis  Media. — Chronic  suppurative  otitis  media 
is  characterized  by  constant  or  recurrent,  offensive,  often  blood-stained 
discharge  from  the  middle  ear,  which  escapes  through  a  defect  in  the 
drumhead.  The  affection  is  indolent,  subject  to  occasional  painful 
exacerbations,  and  may  interfere  very  little  with  hearing.  It  is  often  an 
expression  of  necrosis,  and  then  presents  exuberant  granulations  and  an 
especially  stinking  discharge. 

The  diagnosis  of  middle  ear  disease  is  made  by  direct  examination. 

Polypi. — ^Polypi  of  the  tympanum  are  usually  mucous  in  character,  and 
may  be  evidenced  by  vertigo,  syncope,  vomiting,  and  various  nervous 
manifestations.  They  are  usually  characterized  by  mucopurulent  dis- 
charge and  deafness.     The  diagnosis  is  made  by  direct  examination. 

Cancer. — Cancer  of  the  tympanum  (rare)  may  be  primary  or  secondary 
by  invasion  from  neighboring  tissues. 

Symptoms  are  those  of  cancer  elsewhere,  i.  e.,  rapid  progress  and  inva- 
sion of  all  tissues. 

Cholesteatomata. — Cholesteatomata  form  yellowish  grains  made  up 
of  partly  dried  pus,  epithelium,  fat,  cholesterin  crystals,  and  detritus. 
17 


258  THE  HEAD,  FACE,  AND  NECK 

Symptoms  are  those  of  a  chronic  suppurative  middle  ear  disease.  The 
diagnosis  is  based  upon  the  finding  of  the  yellowish  masses  which  are 
stinking  and  sufficiently  soft  to  crush  between  the  fingers. 

Mastoiditis. — Mastoiditis,  secondary  to  middle  ear  disease,  is  a  common, 
often  unrecognized,  cause  of  high  temperature  and  meningitis  in  infants. 
It  is  characterized  by  pain,  swelling  over  the  mastoid  region,  tenderness  on 
tapping,  and  redness  and  infiltration  of  the  posterior  wall  of  the  bony 
meatus,  associated  with  constitutional  symptoms  of  septic  absorption. 

The  complications  of  acute  or  chronic  inflammation  of  the  tympanum, 
antrum,  or  mastoid  cells  are  meningitis,  sinus  thrombosis,  brain  abscess, 
and  non-suppurating  encephalitis.  Infection  is  usually  direct,  even  in 
case  of  apparently  deeply  placed  brain  abscess. 

These  complications  may  develop  in  the  course  of  an  intercurrent  acute 
attack  of  otitis,  or  in  the  absence  of  this,  and  long  after  discharge  has 
entirely  ceased. 

Acute  encephalitis  appears  as  a  limited  area  of  hemorrhagic  softening, 
and  leaves  on  recovery  a  sclerotic  patch  (Starr).  It  exhibits  the  symp- 
toms of  cerebral  abscess,  nor  can  the  differential  diagnosis  from  this 
condition  be  made  except  by  the  progression  of  septic  and  pressure 
symptoms  in  the  latter  case. 

Cerebral  abscess  usually  in  the  temporosphenoidal  lobe  or  cerebellum 
(p.  236)  is  characterized  by  an  initial  period  of  severe  constant  or 
recurring  headaches,  mental  lethargy,  irregular  temperature  and  pulse, 
followed  shortly  (days  or  weeks)  by  pressure  symptoms,  i.  e.,  slow  pulse, 
abnormal  temperature  (usually  low),  and  late  optic  neuritis.  If  the 
temporosphenoidal  lobe  be  involved,  localizing  symptoms  may  develop 
in  the  form  of  sensory  or  motor  aphasia,  cortical  epilepsy,  facial  palsy. 

If  the  abscess  is  in  the  cerebellum,  staggering  gait  and  vertigo  and 
vomiting  may  be  leading  symptoms.  Death  in  coma  may  occur  quite 
suddenly  without  any  of  these  localizing  symptoms. 

Meningitis  is  evidenced  by  its  severe  pain,  rapidly  progressive  course, 
continued  high  temperature,  rapid  irregular  pulse,  general  hyperesthesia, 
rigidity  of  the  muscles  of  the  back  of  the  neck,  and  the  presence  of 
microorganisms  and  polymorphonuclear  leukocytes  in  the  cerebrospinal 
fluid  obtained  by  lumbar  puncture. 

Sinus  thrombosis  (exceptionally  sterile)  is  characterized  by  the  symp- 
toms of  meningitis  plus  a  more  rapid  and  virulent  systemic  infection. 
The  high  temperature  is  subject  to  sudden  and  violent  fluctuations  with 
recurring  chills.  There  is  at  times  venous  congestion  of  the  side  of  the 
head,  exophthalmos,  and  early  development  of  choked  disks.  Extension 
into  the  neck  is  denoted  by  induration  and  tenderness  along  the  jugular 
vein. 

The  differential  diagnosis  of  these  complications,  one  from  the  other, 
is  of  no  importance  if  acute  encephalitis  be  excepted,  since  they  all 
require  operative  treatment  which  is  successful  in  proportion  to  its 
timeliness. 


THE  EYE  259 


THE  EYE. 


There  are  some  skin  lesions  which  exhibit  a  special  predilection  for 
the  skin  in  the  region  of  the  eyelids. 

Herpes. — Herpes,  an  occasional  expression  of  fever,  is  characterized 
by  vesicular  lesions  which  usually  appear  in  the  form  of  a  cluster  or  a 
coalescent  patch.  Herpes  zoster  is  a  specific  exanthem  the  painful 
vesicular  lesions  of  which  are  grouped  in  irregularly  shaped  inflamed 
patches  along  the  cutaneous  distribution  of  the  frontal  or  nasal  nerve. 
The  area  supplied  by  the  supra-orbital  nerve  is  the  one  commonly 
affected. 

If  the  eruption  involves  the  distribution  of  the  nasal  branch,  conjunc- 
tival vesicles  and  corneal  blebs,  followed  by  ulceration  and  inflammation 
of  the  iris  and  ciliary  body,  are  common  accompaniments. 

Furuncle,  or  Stye. — Furuncle,  or  stye,  a  marginal  boil,  usually  acute  in 
onset,  rapid  in  course,  and  prone  to  recur,  originates  in  a  sebaceous 
gland  or  hair  follicle,  usually  near  the  free  border  of  the  dermal  surface 
of  the  upper  lid. 

The  pre-auricular  lymphatic  gland  is  often  enlarged. 

Acute  Chalazion. — Acute  chalazion  presents  much  the  appearance  of  a 
stye.     It  arises  in  a  meibomian  gland. 

Blepharitis. — Blepharitis  or  marginal  inflammation  of  the  eyelids  may 
be  non-ulcerative  or  ulcerative. 

Ciliary,  or  non-ulcerative,  blepharitis,  the  commonest  form  is  char- 
acterized by  redness  and  slight  thickening  of  the  margins  of  the  lids  with 
the  formation  of  scales  and  small  crusts.  It  is  a  form  of  seborrhea  of 
the  lid  margin  and  is  often  accompanied  by  seborrhea  of  the  eyebrows 
and  scalp. 

Ulcerative  blepharitis  is  a  special  localization  of  eczema  on  the  lid 
border.  The  discharge  is  more  obvious  than  in  the  previous  variety,  the 
crusting  more  marked,  and  pustules  and  ulcers  develop  along  the  lid 
margins  which  in  their  cicatrization  cause  marked  deformity.  The 
eyelashes  may  be  turned  in  or  out  or  may  be  entirely  shed.  The  external 
commissure  is  usually  ulcerated,  and  cicatrices  form  here,  while  a  similar 
condition  about  the  internal  commissure  causes  deviation  of  the  lacry- 
mal  points  or  even  their  entire  obliteration,  with  consequent  epiphora. 

Chancre. — Chancre  forms  an  ulcerating,  indurated  surface  which  may 
manifest  pronounced  inflammatory  swelling.  The  rapid  course  (days  or 
weeks),  the  induration,  the  presence  of  the  specific  microorganism,  and 
the  glandular  adenopathy  are  characteristic  (pre-auricular  if  the  lesion 
involve  the  outer  portion  of  the  lower  lid;  submaxillary  if  elsewhere). 

Lupus. — Lupus  attacks  the  lids  by  extension  from  neighboring  parts, 
and  appears  in  the  form  of  reddish  tubercles  which  usually  terminate 
in  ulceration  and  cicatrization. 

Milium. — The  eyelids  are  especially  the  seat  of  minute  cysts  due  to 
obstruction  of  the  sebaceous  glands,  forming  whitish  grains  at  times  so 
numerous  as  to  occasion  considerable  disfigurement. 


260  THE  HEAD,  FACE,  AND  NECK 

Small  translucent  tumors  from  the  sudoriferous  glands  are  occasionally 
seen  at  the  borders  of  the  eyelids. 

Chalazion,  a  benign  newgrowth  occurring  in  connection  with  a  mei- 
bomian gland,  and  commonly  attended  with  retention  of  the  secretion, 
forms  a  rounded,  yellowish  or  red,  semitranslucent,  dense  tumor,  usually 
about  the  size  of  a  pea,  and  closely  adherent  to  the  tarsal  cartilage. 
The  direction  of  growth  may  be  inward  or  toward  the  skin. 

Xanthoma. — Xanthoma  is  characterized  by  the  development,  usually 
on  the  upper  lids,  of  flat,  slightly  raised,  non-indurated,  non-inflammatory 
concentric  patches  of  yellow  discoloration. 

Molluscum  Contagiosum. — Molluscum  contagiosum  forms  typical  flat, 
rounded,  split-pea  sized,  waxy  elevations  exhibiting  a  dark  colored 
aperture  from  which  curdy  material  can  be  expressed,  and  is  associated 
with  similar  lesions  elsewhere. 

Angioma. — Angiomata,  particularly  in  the  form  of  birthmarks,  are  fre- 
quent. 

Plexiform  neuroma  forms  a  disfiguring  tumor,  involving  the  skin  and 
subcutaneous  tissue,  sometimes  associated  with  diffuse  lymphangioma 
and  hemangioma. 

Papilloma.- — Papilloma  is  fairly  common  on  the  lids.  It  may  become 
pedunculated,  or  on  an  elderly  person  undergo  epitheliomatous  degenera- 
tion. 

Cutaneous  horns  have  been  observed. 

Epithelioma. — Epithelioma,  fairly  frequent,  is  observed  most  commonly 
at  the  inner  portion  of  the  lower  lid  after  the  fortieth  year.  Blepharitis 
is  a  predisposing  factor.  A  wart  or  seborrheic  patch  is  often  the  starting 
point.  It  begins  as  a  small,  superficial,  persistent  ulceration.  It  is  slow 
(years)  in  progression  and  usually  of  the  rodent  ulcer  type,  ultimately 
destroying  all  the  neighboring  structure  including  the  eyeball.  The 
diagnosis  should  be  made  early  by  wide  excision  and  microscopic 
examination. 

Sarcoma  and  Carcinoma. — Sarcoma  and  carcinoma  of  the  lids  (rare) 
conform  to  type  in  that  they  grow  rapidly  (weeks,  months).  Diagnosis 
should  be  made  early  by  wide  excision  and  microscopic  examination.  It 
would  be  suggested  by  exclusion  of  other  causes  for  tumor  formation 
and  the  absolute  failure  of  less  radical  means  of  treatment. 

Epiphora. — Epiphora,  or  habitual  overflow  of  tears  upon  the  cheeks,  may 
be  due  to  deviation  of  the  puncta  lacrymalia  incident  to  inflammatory 
swelling,  cicatricial  contracture,  or  paralysis  of  the  orbicular  muscle; 
to  narrowing  or  closure  of  the  puncta  or  canaliculi,  by  inflammation, 
polypoid  growth,  or  tear  stone,  to  dacryocystitis  or  inflammation  of  the 
lacrymal  sac,  or  to  stricture  or  obliteration  of  the  lacrymal  duct. 

Deviation  or  obstruction  of  the  puncta  or  canaliculi  can  be  detected 
by  inspection  and  gentle  probing. 

Dacryocystitis. — Dacryocystitis  is  characterized  by  a  swelling  just  below 
the  inner  canthus  of  the  eye  from  which  pus  or  mucus  can  be  pressed 
through  the  puncta  lacrymalia. 

Acute  inflammation  is   marked   by  pronounced  swelling  centring  in 


THE  EYE  281 

the  position  of  the  sac,  but  spreading  widely  and  giving  constitutional 
symptoms  of  septic  absorption. 

Fistula  may  follow  suppuration,  much  resembling  the  sinuses  not 
infrequent  near  this  position  as  the  result  of  syphilitic  or  traumatic 
caries  of  the  lacrymal  bone. 

Stricture  of  the  Nasal  Duct. — Stricture  of  'the  nasal  duct  usually  at  its 
extremities  is  consequent  upon  a  chronic  catarrhal  condition  of  the 
mucous  membrane.  It  may  be  caused  by  nasal  catarrh,  necrosis  of  the 
bone,  trauma,  or  the  pressure  of  growing  tumors.  Its  presence  is  deter- 
mined by  the  use  of  lacrymal  bougies,  or  by  injecting  fluid  through  the 
canal  with  an  Anel  syringe. 

Affections  of  the  Conjunctiva. — Hyperemia. — ^This  affection,  some- 
times called  dry  catarrh,  since  it  is  unaccompanied  by  discharge,  is 
characterized  by  an  injection  chiefly  of  the  bulbar  vessels  and  some 
swelling  of  the  conjunctival  follicles.  Its  chief  causes  are  eyestrain, 
exposure  to  local  irritants  (for  example,  dust  and  smoke),  the  abuse  of 
alcohol,  nasal  catarrh,  acute  coryza,  or  hay  fever. 

Sometimes  an  acute  hyperemia  is  sudden  in  onset,  and  is  associated 
with  profuse  lacrymation  and  a  gritty  sensation  when  the  eyelids  are 
moved.  The  presence  of  a  foreign  body  is  suggested,  nor  can  this 
possibility  be  eliminated  except  as  the  result  of  careful  examination, 
including  eversion  of  the  lid  and  inspection  of  the  upper  cul-de-sac. 

Certain  stubborn  hyperemias  of  the  conjunctiva  are  of  constitutional 
origin,  and  may  be  significant  of  gout  and,  in  general  terms,  lithemia. 

Conjunctivitis. — ^This  is  a  true  inflammation  of  the  conjunctiva,  and  is 
evidenced  by  redness  and  swelling  of  this  membrane,  increased  and 
usually  altered  secretion,  lacrymation,  some  photophobia,  and  burn- 
ing pain.  Certain  definite  varieties  of  this  disease  require  special 
mention : 

Simple,  or  Catarrhal  Conjunctivitis. — In  this  affection  there  are  con- 
gestion and  loss  of  transparency  of  the  tarsal  conjunctiva,  moderate  dread 
of  light,  and  a  mucous  and  later  mucopurulent  discharge  which  slightly 
glues  the  lids.  Such  a  conjunctivitis  may  be  associated  with  eczema, 
nasal  catarrh,  bronchitis,  and  various  fevers,  or  may  be  of  mechanical 
origin  from  exposure  to  wind  and  dust,  and  is  not  specially  contagious, 
nor  are  microorganisms  of  specific  character  found  in  its  secretion, 
although  the  ordinary  pus  organisms,  for  example,  staphylococci  and 
streptococci,  may  be  demonstrated.  All  ages  of  life  are  liable  to  catarrhal 
conjunctivitis,  but  it  is  more  frequently  observed  in  children  and  young 
persons. 

Acute  Contagious  Conjunctivitis. — There  are  several  varieties  of  this 
disease  which  in  its  symptoms  resembles  an  exaggerated  catarrhal 
conjunctivitis.  After  an  incubation  period  of  about  thirty-six  hours  a 
severe  form  of  inflammation  develops,  with  thick,  stringy,  mucopurulent 
discharge,  swelling  of  the  retrotarsal  folds,  and  not  infrequently  small, 
subconjunctival  hemorrhages.  Occasionally  the  inflammation  is  suflS- 
ciently  violent  to  produce  a  distinct  chemosis  of  the  conjunctiva.  The 
acute  stage  lasts  from  four  to  ten  days.     The  disease  may  occur  at  any 


262  THE  HEAD,  FACE,   AND  NECK 

age,  is  commonest  in  warm  and  changeable  weather,  and  is  markedly 
contagious.  The  active  microorganism  is  the  so-called  Koch- Weeks 
bacillus. 

Another  form,  which  in  all  clinical  respects  resembles  the  one  just 
described,  is  due  to  the  presence  of  the  pneumococcus,  and  like  the  Koch- 
Weeks  bacillus  conjunctivitis,  is  intensely  contagious,  and  may  occur  in 
epidemics. 

Another  form  is  characterized  by  less  marked  inflammatory  symptoms, 
the  discharge  is  thinner  and  more  copious,  and  the  majority  of  the  cases 
occur  in  young  children,  even  in  infants,  in  whom  the  affection  is  much 
more  severe  than  in  adults.  The  active  microorganism  is  the  influenza 
bacillus,  which  has  many  morphological  characteristics  resembling  the 
Koch- Weeks  bacillus. 

Diplobacillus  conjunctivitis,  due  to  the  Morax-Axenfeld  bacillus, 
usually  runs  a  subacute,  rather  tedious  course,  especially  characterized  by 
soreness  of  the  commissural  angles.  It  may  also  appear  in  acute  mani- 
festations with  free  discharge.  It  is  quickly  cured  by  lotions  of  sulphate 
of  zinc  which  is  practically  a  specific  remedy  in  this  affection. 

Diphtheritic  Conjunctivitis.— DiphtheTitic  conjunctivitis,  at  least  the 
deep-seated  or  necrotic  variety  of  the  disease,  is  characterized  by  a  board- 
like, painful  swelling  of  the  lids,  a  scanty,  seropurulent  or  sanious  dis- 
charge, and  exudation  within  the  layers  of  the  tarsal  conjunctiva,  which 
may  spread  to  the  ocular  conjunctiva.  It  is  commonest  between  the 
ages  of  two  and  eight.  At  one  time  chiefly  seen  in  France  and  Northern 
Germany,  in  recent  years  it  has  become  more  frequent  in  America  and 
in  England.  The  Klebs-Loeffler  bacillus  is  found  in  the  secretion, 
and,  unless  the  process  is  checked,  there  will  be  rapid  sloughing  of  the 
cornea. 

Gonorrheal  Conjunctivitis. — This  may  occur  in  babies  and  is  usually 
known  under  the  term  ophthalmia  neonatorum,  the  infection  being 
derived  during  birth  from  the  genital  passages  of  the  mother.  In 
adults  it  is  called  gonorrheal  ophthalmia,  and  is  inoculated  by  fingers 
soiled  by  a  gonococcal  discharge. 

The  disease  is  characterized  by  a  rapid,  acute  course.  An  abundant 
secretion  of  thick,  greenish  pus  rapidly  supervenes,  pronounced  swelling 
of  the  conjunctiva  appears,  which  in  its  ocular  portion  may  overlap  the 
cornea,  and  in  its  palpebral  portion  may  project  as  a  thick,  edematous 
fold  beneath  the  enormously  swollen  lids.  The  diagnosis  can  be 
promptly  made  by  examining  the  secretion  and  finding  the  gonococcus 
of  Neisser. 

All  forms  of  acute  purulent  conjunctivitis  may  be  complicated  by 
corneal  ulceration.  This  is  uncommon  in  acute  contagious  conjunc- 
tivitis, but  is  exceedingly  likely  to  occur  in  diphtheritic  or  gonococcic 
inflammation. 

From  the  therapeutic  and  prognostic  point  of  view  an  early  determin- 
ation of  the  cause  of  the  acute  conjunctivitis  is  of  major  importance. 
This  can  be  made  only  by  microscopic  and  bacteriological  examin- 
ation of  the  secretion  and  the  detection  of  the  microorganism  which 


THE  EYE  263 

is  active,  though  a  history  of  exposure  to  diphtheria  or  gonorrhea  will 
be  suggestive. 

Many  forms  of  purulent  conjunctivitis,  also  in  newborn  infants, 
are  due  to  microorganisms  other  than  the  Neisser  coccus,  for  example, 
the  pneumococcus,  the  Koch- Weeks  bacillus,  the  bacterium  coli,  etc., 
and  are  not  so  serious  in  their  prognostic  import. 

Phlyctenular  Conjunctivitis. — This  is  characterized  by  pinhead-sized 
yellowish  or  dirty  white  spots  on  the  ocular  conjunctiva,  each  form- 
ing the  apex  of  a  triangle  of  dilated  bloodvessels  radiating  from  this  point 
to  the  conjunctival  cul-de-sac.  These  points  may  suppurate  or  become 
implanted  on  the  cornea  and  develop  into  corneal  ulcerations.  The 
symptoms  are  aggravated  when  the  phlyctenulse  are  multiple,  or  are 
complicated  by  corneal  ulceration.  They  are  probably  a  manifestation 
of  tuberculous  infection. 

Granular  conjunctivitis,  or  trachoma,  is  a  contagious  affection  among 
those  poorly  nourished  and  closely  crowded.  It  is  commonest  among  the 
Russian  and  Polish  Jews  and  the  Italians.  Children  under  ten  years 
old  are  less  liable  to  the  disease  than  adults. 

Trachoma  is  evidenced  by  slight  swelling  and  ptosis  of  the  upper 
lid  which  on  eversion  exhibits  small  red  or  yellowish,  semitranslucent, 
fleshy  elevations  which  have  been  compared  to  grains  of  tapioca.  There 
is  ultimately  always  an  associated  conjunctivitis  followed  by  cicatricial 
deformity  of  the  lids,  and  vascularization  (pannus)  and  ulceration  of  the 
cornea. 

Follicular  conjunctivitis  due  to  lymphoid  overgrowth  of  the  follicles 
appears  in  the  form  of  a  catarrhal  conjunctivitis  of  moderate  severity 
associated  with  a  linear  arrangement  of  minute  semitranslucent,  light 
red  grains  in  the  conjunctiva  of  the  lower  lid  which  externally  is  red- 
dened and  swollen. 

It  differs  from  trachoma  in  that  it  causes  neither  cicatrices  of  the  lid 
nor  corneal  vascularization  nor  ulceration. 

Xerosis,  or  preternatural  dryness  of  the  conjunctiva,  one  of  the  sequels 
of  neglected  trachoma,  is  obvious  on  inspection. 

Chancre  has  been  observed  primarily  on  the  conjunctiva.  Lipoma 
or  angioma,  polyps,  small  cysts  movable  with  the  conjunctiva,  and 
dermoids  have  been  noted. 

Epithelioma  and  sarcoma  are  usually  secondary. 

Affections  of  the  Orbit. — Contusions. — Contusion  of  the  orbital 
margin  is  characterized  by  abundant  subcutaneous  blood  effusion 
which  may  swell  the  lids  shut  in  a  few  minutes.  The  vulnerating  force 
may  cause  fracture  which  makes  a  direct  communication  between  the 
orbit  and  the  nose  or  its  sinuses.  The  resultant  hemorrhage  may  be 
expressed  in  the  form  of  bleeding,  subconjunctival  hemorrhage,  chemosis, 
and,  if  extensive,  exophthalmos.  Crackling  on  pressure  is  indicative  of 
communication  with  the  nasal  cavities. 

Fracture.- — Fracture  of  the  orbital  brim  may  be  detected  by  palpation, 
gentle  massage  enabling  the  surgeon  to  reach  the  bone  even  through  a 
considerable  blood  effusion. 


264  THE  HEAD,  FACE,  AND  NECK 

Fracture  of  the  roof  of  the  orbit,  usually  caused  by  violence  applied  to 
the  forepart  of  the  vault  of  the  skull,  in  addition  to  the  brain  symptoms 
consequent  upon  trauma  sufficiently  severe  to  cause  this  injury,  may  be 
characterized  by  subconjunctival  hemorrhage  and  at  times  blindness, 
since  the  optic  foramen  and  consequently  the  optic  nerve  may  be  involved 
in  this  fracture. 

Inflammation. — Acute  inflammation  of  the  cellulo-fatty  tissue  of  the 
orbit,  characterized  by  chemosis  of  the  conjunctiva,  exophthalmos,  red, 
swollen,  projecting  lids,  and  pronounced  constitutional  symptoms  of 
infection  is  usually  secondary  to  inflammation  of  neighboring  parts. 
Accessory  sinus  empyema,  and  the  orbital  thrombosis  or  lymphatic 
extension  from  carbuncle,  boil,  or  erysipelas  of  the  face  are  the  com- 
mon causes.  The  orbital  cellulitis  may  be  secondary  to  contusion 
with  fracture  into  the  sinuses,  to  direct  wound,  or  to  systemic  infection 
(scarlet  fever,  typhoid,  influenza,  erysipelas).  The  most  common  cause 
is  infection  from  the  accessory  nasal  sinuses. 

The  diagnosis  suggested  by  the  symptoms  given  and  usually  by  a 
preceding  adjacent  infection,  and  is  corroborated  by  incision. 

In  the  virulent  forms  of  orbital  cellulitis  secondary  to  facial  erysipelas 
or  carbuncle,  or  to  the  extension  of  septic  thrombosis  from  the  cavernous 
sinus,  death  usually  occurs  before  free  pus  formation. 

Edema,  chemosis,  and  exophthalmos  incident  to  blood  effusion  or 
non-infected  cavernous  sinus  thrombosis  would  not  be  attended  by 
septic  symptoms. 

Tumors  of  the  Orbit. — ^The  diagnosis  of  tumor  of  the  orbit  is  usually 
based  upon  a  visible,  palpable,  circumscribed,  non-inflammatory  swelling, 
which  in  the  case  of  vascular  tumors  varies  in  size  and  consistency  in 
accordance  with  vascular  tension  and  which  may  pulsate. 

The  benign  tumor  grows  slowly,  the  malignant  rapidly.  When  the 
diagnosis  between  these  is  doubtful  it  should  be  made  by  excision  and 
microscopic  examination. 

Osteomata  or  exostoses  appear  as  bony  outgrowths  from  the  orbital 
walls,  often  from  the  frontal  sinus,  and  are  characterized  by  slow  growth, 
density  of  structure,  and  displacement  of  the  eyeball.  The  a;-ray  picture 
is  diagnostic. 

When  too  deeply  placed  to  be  seen  or  felt,  the  symptoms  which  may 
suggest  diagnosis  are  pain,  displacement  of  the  eyeball,  interference  with 
the  action  of  the  extrinsic  eye  muscles,  and  venous  congestion  of  the 
eyelids  and  surrounding  skin. 

Tumors  which  arise  from  the  orbital  contents  include  hemangioma, 
lymphangioma,  lipoma,  fibroma,  lymphoma,  neuroma,  simple  and  plexi- 
form,  and  sarcoma,  with  which  should  be  included  endothelioma. 

Simple  angioma  usually  starts  from  a  nevus  of  the  lids  extending 
inward.  Sometimes  it  follows  trauma.  It  forms  a  soft,  pendulous, 
usually  harmless  mass  in  the  upper  part  of  the  orbit,  the  tension  of  which 
is  increased  by  straining  efforts. 

Cavernous  angioma,  of  slow  development,  causes  exophthalmos 
markedly   increased   by  straining  efforts.     This,  together  with   its  ill- 


THE  EYE  265 

defined  outline,  its  apparent  reducibility,  and  its  change  in  size  incident 
to  vascular  tension,  is  characteristic.  Varices  are  described,  particularly 
in  the  upper  inner  portion  of  the  orbit. 

Pulsatile  tumor  of  the  orbit,  or  pulsating  exophthalmos,  usually 
traumatic  in  origin,  incident  to  basal  fracture,  is  characterized  by  tin- 
nitus, followed  by  venous  congestion  about  the  lids,  bruit,  pulsation, 
exophthalmos,  usually  unilateral,  and  chemosis.  The  usual  cause  is  an 
arteriovenous  aneurysm  (internal  carotid  and  cavernous  sinus). 

Palpation  may  reveal  a  tumor  in  the  upper  inner  portion  of  the  orbit 
made  up  of  dilated  vessels  in  which  thrill  can  be  distinctly  felt.  Vision 
is  not  always  interfered  with,  though  there  is  commonly  palsy  of  the 
extrinsic  muscles,  particularly  the  external  recti.  In  many  cases,  however, 
there  are  retinal  hemorrhages  and  often  neuritis  and  optic  nerve  atrophy. 

Plexiform  neuroma  (rare)  is  a  congenital  tumor  associated  with  a 
similar  growth  in  the  surrounding  skin. 

The  lymphoma  (Hochheim)  may  be  simple,  pseudoleukemic,  or  of 
doubtful  nature.  Leukemic  tumors  in  both  orbits  occasionally  appear 
in  the  form  of  multiple  nodules  associated  with  the  symptoms  of  general 
leukemia. 

Growths  that  have  been  called  tuberculous  are  really  extensions  into 
the  orbit  from  a  tuberculous  periostitis  often  at  the  orbital  margin  where 
an  induration  forms  which  softens  and  discharges  a  purulent  material 
unassociated  with  inflammatory  signs. 

Sarcoma  of  the  orbit,  rare  as  a  primary  tumor  and  usually  observed 
in  young  persons,  may  appear  as  spindle-cell,  round-cell,  or  angiosar- 
coma, or  most  exceptionally  as  melanosarcoma.  The  growth  develops 
rapidly  (weeks  or  months),  at  times  following  trauma,  and  sometimes 
projects  externally  beneath  the  conjunctiva  as  a  soft,  elastic,  lobulated 
tumor,  which,  depending  upon  its  structure,  may  pulsate  and  appa- 
rently fluctuate.  Osteosarcomata  may  develop  slowly  (months,  years). 
Metastasis  occurs  early  in  the  small  round-cell  growths,  taking  place 
through  the  blood  stream;  at  a  later  period  in  the  fibrosarcomata.  True 
endotheliomata,  often  classified  with  the  sarcomata,  have  only  a  local 
malignancy. 

Primary  sarcomata  must  not  be  confounded  with  those  which  appear 
in  the  orbit  as  extensions  from  the  neighboring  sinuses  and  from  the 
choroid  after  rupture  of  the  sclera.  Under  the  last-named  circum- 
stances the  growth  is  almost  invariably  pigmented. 

Carcinoma  grows  from  the  lacrymal  gland  and  closely  resembles 
sarcoma  in  its  development. 

The  diagnosis  of  malignant  orbital  tumors  should  be  made  by  excision 
and  microscopic  examination  of  all  tumors  not  obviously  benign. 

Cysts  of  the  orbit  are  congenital  or  acquired.  The  congenital  cysts 
include  dermoids,  teratoid  cysts,  inclusion  cysts,  meningoceles,  and 
encephaloceles. 

Teratoma  (rare)  appears  obviously  at  birth  associated  with  marked 
deformity  of  the  eye. 

Encephalocele  and  meningocele,  common  at  the  upper  inner  angle 


266  THE  HEAD,  FACE,  AND  NECK 

of  the  orbit  and  the  position  of  the  lacrymonasal  canal,  are  present  at 
birth,  and  exhibit  an  underlying  bony  defect,  though  this  cannot  always 
be  felt.  Characteristic  symptoms  are  usually  absent,  and  the  tumor 
may  readily  be  confounded  with  lacrymal  hydrops  or  cold  abscess  of 
the  bone.  Reducibility  and  changes  in  tension  incident  to  straining 
efforts  would  be  diagnostic  if  present. 

Dermoids,  the  commonest  form  of  orbital  cyst,  are  commonly  placed 
in  the  upper  outer  angle  of  the  orbit.  They  are  indolent,  rounded  tumors, 
usually  not  detected  until  about  the  age  of  puberty,  when  they  begin  to 
grow.  They  produce  trouble  only  by  mechanically  displacing  the  tissues 
of  the  orbit. 

The  acquired  cysts  include  implantation  cysts  derived  from  the 
conjunctiva,  and  serous  cysts,  which  are  of  obscure  etiology  and  may 
possibly  arise  in  connection  with  the  sheaths  of  the  extrinsic  muscles  in 
the  form  of  bursae.  Serous  cysts  may  also  be  derived  from  hemorrhage 
in  the  orbit  after  degeneration  of  a  blood  clot.  Extravasated  blood  in 
the  retrobulbar  tissue  may  become  encapsulated  and  simulate  a  blood 
cyst. 

Inflammatory  Affections  of  the  Cornea. — The  cardinal  symptoms 
of  these  affections  are  corneal  opacity,  usually  associated  with  a  peri- 
corneal ring  of  injected  bloodvessels,  pain,  photophobia,  blepharospasm, 
hypersecretion  of  tears,  and  obscured  vision. 

Foreign  Body. — Foreign  body  embedded  in  the  cornea  causes  first  the 
symptoms  of  hyperemic  conjunctivitis  with  severe  pain  on  motion  of  the 
lids,  usually  referred  to  the  position  of  the  superior  cul-de-sac.  Corneal 
ulcer  with  its  characteristic  symptoms  develops  later. 

The  detection  of  a  minute  body  is  accomplished  by  obliquely  illumi- 
nating the  cornea  from  the  side  by  focussing  light  upon  it  through  a  lens 
while  the  observer  inspects  from  in  front  through  a  hand  magnifying 
glass ;  or  by  dropping  upon  the  cornea  a  solution  of  fluorescein  (2  per  cent.) 
which  colors  green  the  abraded  cornea  and  surrounds  the  dark  foreign 
body  by  a  green  colored  area. 

Phlyctenular  keratitis,  common  in  strumous,  catarrhal  children  who 
are  convalescent  from  an  exanthem,  is  characterized  by  the  formation  of 
minute  disseminated  vesicles  or  pustules  in  the  outer  corneal  surface 
resulting  in  superficial  ulcers.  The  deeper  forms  leave  scars.  Photo- 
phobia is  intense,  relapses  are  frequent.  Eczema  of  the  nares  and  scalp 
and  the  lesions  and  symptoms  of  an  infective  rhinitis  are  commonly 
present. 

Ulcerations. — Ulcerations,  superficial  or  deep,  acute  or  chronic,  cen- 
trally or  laterally  placed,  may  perforate  the  cornea,  or,  if  they  be  acutely 
infected  or  sloughing  (pneumococcus),  may  be  complicated  by  pus  in  the 
anterior  chamber.  The  ulceration  occurs  in  those  vitally  depressed  and 
as  a  result  of  traumatism  or  acute  inflammation  (conjunctivitis). 

Neuropathic  ulceration,  characterized  by  central  necrosis  and  perfor- 
tion,  is  secondary  to  direct  irritation  of  an  eye  which  has  lost  its  sensi- 
bility and  is  no  longer  protected  by  the  lids,  because  of  blocked  innerva- 
tion (trigeminal).     It  is  a  common  sequel  of  Gasserian  ganglion  removal. 


THE  EYE  267 

Vascular  Keratitis. — Vascular  keratitis  is  secondary  to  trachoma  and 
recurrent  phlyctenular  keratitis.  Over  the  clear  corneal  window  there 
sweeps  from  above  and  below  (weeks  or  months)  a  veil  of  fine  blood- 
vessels preceded  by  a  fringe  of  opacity. 

Interstitial  Keratitis. — This  is  usually  due  to  hereditary  syphilis,  not 
infrequently  to  tuberculosis,  and  is  characterized  by  corneal  opacity  due 
to  a  central  infiltration,  resembling  ground  glass.  There  is  always  pro- 
nounced vascularization,  forming  reddish  patches,  which  may  invade 
the  entire  cornea.     Ulceration  is  rare. 

Inflammatory  Affections  of  the  Iris. — Iritis. — Iritis  is  character- 
ized by  change  in  color  and  blurring  of  striation,  a  circumcorneal  zone 
of  congestion,  contracted  pupil  reacting  sluggishly  or  not  at  all  to  mydri- 
atics, with  adhesions  to  the  capsule  of  the  lens  (posterior  synechium), 
haziness  of  the  cornea,  impaired  vision,  severe  pain  in  the  eye,  temple, 
and  forehead,  tenderness  of  the  eyeball,  and  photophobia. 

Plastic  iritis,  the  usual  form  of  the  disease,  is  common  in  the  first  year 
of  acquired  syphilis.  As  an  expression  of  rheumatism,  gout,  or  gon- 
orrhea, it  is  recurrent  in  type. 

Uveitis. — Serous  iritis  is  characterized  by  a  pupil  of  normal  size  or,  in 
its  early  stage,  by  one  even  moderately  dilated,  absence  of  early  adhe- 
sions to  the  lens,  haziness  of  the  aqueous  humor  and  cornea,  with  the 
deposit  on  the  inner  surface  of  this  structure  of  dirty  gray  points  grouped 
in  triangular  form  with  apices  down.  The  anterior  chamber  is  deepened. 
It  occurs  in  late  syphilis  and  in  other  infectious  diseases,  and  may  be  a 
manifestation  of  intestinal  autointoxication.  A  large  percentage  of  the 
cases  are  due  to  tuberculous  infection. 

Acute  Glaucoma. — Acute  glaucoma,  an  affection  of  middle  and  old  age, 
is  characterized  by  increased  hardness  of  the  eyeball,  swelling  of  the 
conjunctiva  and  eyelid,  anesthetic  and  hazy  cornea,  clouded  aqueous 
humor,  fixed  discolored  iris  with  partly  dilated  pupil,  rapid  loss  of  vision, 
and  intense  headache.  The  attack  may  be  preceded  by  a  rapid  failure 
in  accommodation  for  near  objects  characterized  by  a  frequent  change  of 
glasses,  recurring  periods  of  failing  vision,  and  the  perception  of  spectral 
halos  about  artificial  light.  It  should  be  distinguished  from  iritis  by 
the  absence  of  synechise,  the  semidilated  pupil,  and  by  the  marked 
elevation  of  intra-ocular  tension. 

Sympathetic  Inflammation. — Sympathetic  inflammation  of  one  eye 
secondary  to  traumatic  or  perforating  lesions  involving  the  ciliary  body 
of  the  other,  usually  develops  within  the  first  six  weeks  of  the  original 
lesion,  and  is  characterized  by  the  symptoms  of  iridocyclitis.  A  tender 
spot  on  the  ciliary  region  may  precede  obvious  symptoms. 

Sympathetic  irritation  is  characterized  by  photophobia,  failure  of 
accommodation,  and  tenderness  of  the  sympathizing  eye,  and  is 
promptly  relieved  by  removal  of  the  exciting  eye.  It  may  be  regarded 
as  a  neurosis  or  else  as  an  early  stage  of  the  infective  uveitis  just 
described,  which  it  sometimes  precedes. 

Contusion  of  the  Eye. — Sudden  force  applied  to  the  eye  may  cause 
a  flashing  sensation  followed  by  dilatation  of  the  pupil,  obscuration  of 


268  THE  HEAD,  FACE,   AND  NECK 

vision,  or  even  temporary  loss  of^sight;  this  in  the  absence  of  demonstrable 
lesion.  The  diagnosis  is  based  upon  the  transitory  nature  of  the  symptoms 
and  the  exclusion  of  intra-ocular  lesions  by  ophthalmoscopic  examina- 
tion. 

Severe  contusion  usually  causes  hemorrhage  into  the  anterior  chamber, 
obscuring  deeper  lesions,  the  commonest  of  which  are  dislocation  of  the 
lens,  detachment  of  the  ciliary  margin  of  the  iris,  and  blood  effusion 
between  the  retina  and  the  choroid. 

Rupture  of  the  sclera  is  characterized  by  prolapse  of  the  choroid,  or 
escape  of  the  vitreous  into  the  subconjunctival  space  where  it  may  appear 
as  a  yellow-green  jelly.  There  is  usually  abundant  subconjunctival 
hemorrhage. 

Foreign  Body. — Foreign  body  in  the  eye  is  characterized  by  a 
wound  of  entrance  and  intra-ocular  bleeding.  When  the  latter  is  marked, 
the  presence  and  position  of  the  foreign  body  must  be  determined  by  the 
x-rays,  provided  it  is  of  such  nature  that  it  will  cast  a  shadow  on  the 
plate,  i.  e.,  if  it  is  iron  or  steel.  Its  presence  may  also  be  determined  by 
the  use  of  a  large  magnet,  with  which  it  is  drawn  either  into  the  anterior 
chamber,  through  the  wound  of  entrance,  or  through  a  scleral  incision 
placed  according  to  the  findings  of  the  x-ray  plate. 

Paralysis  of  the  External  Ocular  Muscles  of  the  Eye. — ^Paralysis 
of  an  ocular  muscle  may  be  caused  by  an  intracranial  or  an  orbital  lesion. 
The  intracranial  lesion  may  be  cortical,  nuclear,  fascicular,  or  basal  in 
situation.  The  palsies  of  basal  or  orbital  origin  are  due  to  inflamma- 
tory lesions,  tumors,  aneurysm,  hemorrhage,  or  fracture. 

Syphilis  is  the  most  frequent  cause  of  extra-ocular  muscle  palsy,  and 
is  the  potent  factor  in  about  one-half  of  the  cases.  Other  causes 
which  may  occasion  nuclear  or  peripheral  lesions  are  rheumatism,  gout, 
diabetes,  whooping  cough,  influenza,  herpes  zoster,  and  certain  toxic 
agents,  for  example,  lead,  alcohol,  gelsemium,  carbonic  acid  and  various 
ptomains. 

A  paralysis  of  the  external  ocular  muscles  is  seen  in  connection  with 
locomotor  ataxia,  paretic  dementia,  disseminated  sclerosis,  and  bulbar 
paralysis. 

Tabetic  paralysis  is  often  transitory  in  nature,  but  prone  to  relapse, 
and  is  usually  associated  with  the  pupillary  changes  and  motor  and 
sensory  symptoms  characteristic  of  this  affection. 

Paralyses  of  the  orbital  muscles  of  cerebral  origin  may  result  from 
degenerative,  hemorrhagic,  or  neoplastic  lesions  affecting  the  cortex 
of  the  brain,  the  corticopeduncular  region,  the  nuclei  of  the  nerves,  or 
the  nuclear  fibers. 

Palsy  of  traumatic  origin  may  be  immediate  and  complete  incident  to 
direct  injury,  or  to  lesion  consequent  upon  basal  fracture  or  to  pressure 
due  to  hemorrhage.  A  rapidly  (days)  developing  palsy  following 
injury  may  be  due  to  traumatic  reaction;  or,  should  it  come  on  more 
slowly  (weeks),  to  formative  periostitis. 

A  number  of  cases  of  congenital  paralysis  are  on  record,  and  occa- 
sionally congenital  syphilis  is  an  etiological  factor. 


THE  EYE  269 

Paralysis  of  the  abducens  supplying  the  external  rectus  is  most  fre- 
quently encountered;  next  in  order  of  frequency  is  unilateral  paralysis 
of  the  oculomotor.  After  these  come  in  order  paralyses  of  the  superior 
oblique,  inferior  rectus,  superior  rectus,  internal  rectus,  and  inferior 
oblique. 

The  general  symptoms  common  to  paralysis  of  the  external  ocular 
muscles  are  the  following: 

1.  Loss  of  binocular  single  vision,  or  diplopia;  always  most  manifest 
in  that  portion  of  the  field  to  which  the  affected  muscle  normally  rotates 
the  eyeball. 

2.  Strabismus,  quite  evident  if  the  paralysis  is  complete,  demonstrable, 
at  times,  only  when  the  eye  is  turned  toward  the  affected  side,  due  to  the 
unresisted  action  of  the  antagonist  of  the  paralyzed  muscle. 

•  3.  Limitation  of  that  movement  which  is  given  to  the  eye  by  the 
affected  muscle.  The  deviation  of  the  eye  is  always  in  a  direction 
opposite  to  the  action  of  the  muscle. 

4.  False  projection  of  the  field  of  vision.  This  depends  upon  an  in- 
accurate estimation  of  the  position  of  an  object  situated  in  such  a  portion 
of  the  visual  field  that  it  requires  an  effort  on  the  part  of  the  affected 
muscle  to  turn  the  eye  toward  it.  For  example,  if  a  patient  with  a  paretic 
left  external  rectus  is  required  to  touch  an  object  to  the  left  of  the  point 
of  fiLxation,  he  will  pass  his  hand  beyond  it,  that  is,  to  the  left  of  it.  Other 
marked  symptoms  are  vertigo  and  an  altered  position  of  the  carriage  of 
the  head,  which  is  placed  in  such  a  position  as  to  give  the  patient  the 
least  trouble  with  his  double  images. 

If  there  is  complete  paralysis,  a  diagnosis  is  easily  made  by  remember- 
ing the  dominant  action  of  each  ocular  muscle,  namely,  that  the  external 
muscle  rotates  the  eye  outward,  the  internal  rectus  inward,  the  superior 
rectus  upward,  and  the  inferior  rectus  downward,  while  the  superior 
oblique  has  for  its  muscular  actions  intorsion,  that  is,  it  rotates  the 
vertical  meridian  inward  and  also  lowers  and  abducts  the  eye,  while 
the  inferior  oblique  produces  extorsion,  that  is,  it  rotates  the  vertical 
meridian  outward  and  also  elevates  the  eye  and  abducts  it. 

Single  ocular  muscle  palsies  are  often  so  incomplete  that  the  defects 
in  the  rotations  of  the  eyeball  are  not  appreciable  on  inspection.  The 
affected  muscle  must  then  be  determined  by  applying  the  law  of 
diplopia. 

The  patient  seated  with  the  head  and  eyes  in  the  primary  position, 
about  4  meters  from  a  test  object,  for  example,  a  candle  flame,  has  one 
eye  covered  w4th  a-piece  of  red  glass.  If  diplopia  is  developed,  one  image 
wall  be  yellow  and  the  other  red.  The  lighted  candle  is  then  moved 
from  the  median  line  to  the  right,  to  the  left,  upward,  downward,  and 
in  oblique  positions.  Double  images  are  chiefly  seen  when  the  eyes  are 
turned  in  the  direction  requiring  an  action  of  the  affected  muscle.  The 
image  of  the  aflfected  eye,  that  is,  the  false  image,  is  projected  in  a  direc- 
tion toward  w^hich  the  paralyzed  muscle  normally  rotates  the  eye.  Wnen 
the  test  object  is  moved  in  the  direction  of  the  paralyzed  muscle,  the 
distance  between  the  double  images  increases. 


270  THE  HEAD,  FACE,  AND  NECK 

There  are  two  varieties  of  diplopia,  according  to  the  relation  which  the 
double  images  bears  to  the  eyes.  If  the  right  image  pertains  to  the  right 
eye  and  the  left  image  to  the  left  eye,  the  diplopia  is  homonymous;  if 
the  right  image  pertains  to  the  left  eye  and  the  left  image  to  the  right 
eye,  the  diplopia  is  crossed.  If  the  images  are  side  by  side,  that  is  to 
say,  there  is  lateral  diplopia,  either  the  external  or  the  internal  rectus 
is  affected.  If  the  diplopia  is  homonymous  and  is  most  marked  when 
the  test  object  is  carried  into  the  right  field,  the  right  external  rectus 
is  affected.  If  the  diplopia  is  crossed,  there  is  paralysis  of  an  internal 
rectus,  the  internal  rectus  of  the  left  eye  if  the  images  separate  to  the 
right,  and  the  internal  rectus  of  the  right  eye  if  the  images  separate  to 
the  left. 

Vertical  diplopia  in  the  upper  field  indicates  paralysis  of  the  superior 
rectus,  or  the  inferior  oblique;  if  the  vertical  diplopia  is  chiefly  noticed 
in  the  lower  field,  there  is  indication  of  paralysis  of  the  inferior  rectus  or 
the  superior  oblique.  If  the  diplopia  is  homonymous  and  vertical  in  the 
upper  field,  there  is  probably  paralysis  of  an  inferior  oblique,  the  right  if 
the  image  of  the  right  eye  is  higher,  the  left  if  the  image  of  the  right  eye 
is  lower.  If  the  diplopia  is  crossed  and  vertical  in  the  upper  field  only, 
there  is  probably  paralysis  of  a  superior  rectus,  the  right  superior  rectus 
if  the  image  of  the  right  eye  is  higher,  the  left  superior  rectus  if  the 
image  of  the  right  eye  is  lower.  If  there  is  vertical  diplopia  chiefly  in 
the  lower  field  and  it  is  homonymous,  there  is  probably  paralysis  of  a 
superior  oblique,  the  right  superior  oblique  if  the  image  of  the  right  eye 
is  lower,  the  left  superior  oblique  if  the  image  of  the  right  eye  is  higher. 
If  the  diplopia  is  crossed  and  vertical  in  the  lower  field  only,  there  is 
probably  paralysis  of  an  inferior  rectus,  the  right  inferior  rectus  if  the 
image  of  the  right  eye  is  lower,  the  left  inferior  rectus  if  the  image 
of  the  right  eye  is  higher. 

A  certain  number  of  ocular  paralyses  are  associated,  that  is  to  say,  the 
eyes  cannot  make  certain  movements  in  which  they  are  usually  associated, 
although  the  directing  power  of  the  muscles  may  be  uninjured  when  they 
exercise  their  function  in  a  different  association.  For  example,  the 
internal  recti  may  be  unable  to  draw  the  eyes  together  in  the  act  of 
convergence,  although  they  may  act  normally  in  helping  to  move  the  eyes 
from  side  to  side.  These  are  the  conjugate  lateral  paralyses,  and  depend 
upon  lesions  affecting  the  centres  of  combined  movement,  or  upon  sym- 
metrical disease  of  the  nuclei  of  the  affected  nerves. 

Sometimes,  for  example,  in  apoplexy  the  head  is  drawn  from  the 
paralyzed  side  and  the  eyes  are  also  turned  to  the  sound  side,  that  is, 
there  is  conjugate  deviation  of  the  head  and  eyes.  In  lesions  of  the  hemi- 
sphere the  eyes  are  turned  toward  the  lesion  and  away  from  the  paralyzed 
side,  but  in  lesions  of  the  mesencephalon  they  are  turned  away  from  the 
lesion  and  toward  the  paralyzed  side. 

When  there  is  complete  paralysis  of  all  the  muscles  of  the  eye,  the 
term  ophthalmoplegia  is  applied,  that  is  to  say,  there  is  ptosis  and  com- 
plete immobility  of  the  eyeball.  Such  conditions  may  depend  upon 
diseases  of    the  nuclei,  for  example,  a  hemorrhagic   polioencephalitis, 


THE  NOSE  271 

tuberculosis,  syphilis,  ptomain  poisoning,  acute  poliomyelitis,  bulbar 
palsy,  etc. 

If  only  the  branches  of  the  oculomotor  are  affected,  either  peripherally 
or  centrally,  there  is  ptosis  and  complete  immobility  of  the  eyeball  except 
in  so  far  as  the  movements  of  the  external  rectus,  which  is  supplied  by  the 
abducens,  and  the  superior  oblique,  which  is  supplied  by  the  fourth  nerve, 
are  concerned;  outward  movement  and  intorsion,  that  is  to  say,  wheel 
movement  inward,  are  preserved. 

Paralysis  of  the  ophthalmic  division  of  the  fifth  nerve  causes  anesthesia 
of  the  conjunctiva  and  cornea  and  strongly  predisposes  the  latter  tissue 
to  ulceration.  It  has  often  been  noted  after  excision  of  the  Gasserian 
gano'lion. 

Paralysis  of  the  sympathetic  in  the  neck  causes  contraction  of  the 
pupil,  slight  sinking  inward  of  the  eyeball,  and  is  sometimes  a  symptom 
of  cervical  fractures,  tumors,  and  aneurysm. 

The  practitioner  should  be  able  to  make  a  differential  diagnosis  be- 
tween a  concomitant  squint,  one  in  which  the  squinting  eye  follows  in 
all  particulars  the  movements  of  the  non-squinting  eye,  and  a  paralytic 
squint,  one  in  which  the  rotation  in  the  line  of  direction  of  the  action  of 
the  affected  muscle  is  limited.  The  common  crossed  eye  of  childhood 
which  depends  upon  the  presence  of  refractive  error,  usually  hyper- 
metropia,  amblyopia  of  one  eye,  and  failure  of  proper  development  of  the 
fusion  sense,  is  readily  differentiated  from  a  strabismus  caused  by  paralysis 
of  the  external  rectus  by  noting  that  in  the  paralysis  the  outward  move- 
ment of  the  eye  would  be  lost  or  diminished,  while  in  the  concomitant 
strabismus  it  is  unimpaired.  Diplopia  in  association  with  concomitant 
strabismus  is  unusual.  If  sought  for  it  is  always  found  in  the  various 
types  of  paretic  or  paralytic  strabismus. 


THE  NOSE. 

The  nose  forms  the  channel  for  normal  respiration,  contains  the 
organs  of  smell,  is  an  important  adjunct  to  the  sense  of  taste,  and  imparts 
resonance  to  the  voice.  The  symptoms  of  its  disease  are  deformity, 
anterior  or  posterior  discharge,  nasal  obstruction,  attested,  if  bilateral, 
by  mouth  breathing  and  nasal  speech,  and  loss  or  diminution  of  the  sense 
of  smell.     Because  of  the  great  vascularity  bleeding  is  common. 

Chronic  mucous  or  mucopurulent  discharge  is  symptomatic  of 
hypertrophic  or  atrophic  rhinitis,  or  of  catarrh  secondary  to  obstruction 
from  polyps,  tumors,  deviated  septum  or  non-ulcerating,  syphilitic  in- 
filtration. Chronic,  frankly  purulent,  abundant  discharge  is  usually 
due  to  sinus  empyema,  dead  bone,  or  foreign  body. 

Free  hemorrhage  (epistaxis)  is  usually  traumatic.  If  slight  but 
dangerously  persistent,  is  hemophilic.  It  is  symptomatic  of  Bright's 
disease,  cirrhosis,  cardiopathies,  gout,  typhoid,  indeed,  all  eruptive 
fevers.  It  is  common  in  children,  and  is  in  them  usually  due  to  a  slight 
underlying  mucous  membrane  lesion.     It  is  at  times  menstrual.     Excep- 


272  THE  HEAD,  FACE,  AND  NECK 

tionally,  it  is  associated  with  intranasal  angioma.  Free  serous  dis- 
charge is  observed  in  the  early  stage  of  acute  coryza;  if  continuous  and 
not  associated  with  inflammatory  symptoms,  it  is  cerebrospinal  fluid 
(fracture  of  the  base,  hydrocephalus). 

Examination  of  the  nasal  cavities  is  conducted  by  means  of  a  head- 
light, a  dilating  speculum,  and  long-handled  rhinoscopic  mirrors.  It 
is  preceded  by  swabbing  the  nasal  mucous  membrane,  the  base  of  the 
tongue,  both  surfaces  of  the  soft  palate,  and  the  nasopharynx  with  a 
10  per  cent,  solution  of  eucaine  lactate,  containing  adrenalin  chloride 
1  to  10,000. 

Digital  examination  of  the  nasopharynx  is  serviceable  when  the  mirrors 
cannot  be  used. 

Congenital  Deformities. — ^The  nose  may  be  double  or  bifid.  The 
nostrils  may  be  narrowed  or  occluded,  in  the  latter  case  usually  far  back, 
by  a  diaphragm. 

Acquired  deformities  incident  to  traumatism  or  inflammation  (usually 
syphilitic)  are  characterized  by  lateral  deviation,  or  sinking  in  of  the 
bony  or  cartilaginous  framework,  or  both,  or  occlusion  of  the  nostrils  by 
septal  overgrowth  or  adhesions  between  the  septum  and  the  turbinates. 

Traumatisms. — Contusion. — This  is  characterized  by  free  bleeding  from 
the  nostrils,  usually  moderate,  subcutaneous  blood  effusion,  and  swell- 
ing. There  may  be  found  a  septal  hematoma  forming  a  dark,  rounded, 
soft  projection  partially  or  completely  obstructing  the  nostril.  When 
these  blood  bosses  are  found  on  both  sides  of  the  septum,  and  particularly 
when  there  is  intercommunication  between  them,  fracture  is  present. 

Fracture. — Fracture  of  the  nose  is  usually  found  in  the  lower  third  of 
the  nasal  bones  and  the  cartilaginous  septum.  The  nasal  process  of  the 
superior  maxillary,  the  lacrymal,  the  sphenoid,  or  the  ethmoid  may  be 
involved.  These  fractures  are  often  comminuted,  and,  because  of  the 
closely  applied  mucous  membrane,  there  is  free  epistaxis,  often  subcu- 
taneous emphysema  which  may  appear  in  the  orbit  and  produce  exoph- 
thalmos. In  the  absence  of  great  swelling,  deformity  and  crepitus  are 
elicited  without  difficulty. 

The  septum  should  always  be  examined,  since  a  break  in  its  cartilagi- 
nous portion  or  disjunction  of  this  portion  from  its  union  with  the  vomer 
is  common.  In  either  case,  if  there  be  overlapping,  the  nose  will  be 
sunken,  deviated,  and  preternaturally  mobile.  Bilateral  septal  bosses 
are  characteristic,  and,  by  means  of  a  probe  or  the  finger,  deformity  can 
be  felt  and  corrected. 

Force  sufficient  to  fracture  the  base  of  the  nasal  bone  is  usually  com- 
plicated by  a  basal  fracture  and  brain  symptoms.  It  is  also  likely  to 
involve  the  perpendicular  plate  of  the  ethmoid. 

Affections  of  the  Nasal  Orifice  and  Vestibule. — Erysipelas. — 
Erysipelas  has  its  common  point  of  departure  from  about  the  nose  (see 

P-^^)-  ...  ■  . 

Furuncle. — Furuncle  commonly  placed  just  within  the  nasal  orifice, 

often  recurring,  is  characterized  by  the  severe  pain  which  it  causes  in  this 

position. 


THE  NOSE  273 

Acute  erythema  and  eczema  are  common  accompaniments  of  nasal 
catarrh. 

Acne  Rosacea. — The  thick,  vascular,  closely  adherent  skin  overlying 
the  alse  and  tip  of  the  nose  is  peculiarly  subject  to  acne  and  vascular 
dilatation,  producing  a  red,  nodular  overgrowth  common  in  habitual 
drinkers  but  not  confined  to  them. 

Ulcerations. — Ulcerations  are  syphilitic,  tuberculous,  or  malignant. 
Chancre  may  begin  on  the  skin  surface  or  just  within  the  nostril;  in 
the  latter  case  incident  to  infection  carried  by  the  finger.  The  apparent 
causelessness,  the  rapid  growth  (weeks),  the  induration,  the  subjective 
symptoms,  and  particularly  the  characteristic  adenopathy,  should  at 
least  suggest  a  diagnosis.  A  septal  chancre  is  usually  not  suspected  until 
secondary  eruptions  develop. 

Tuberculous  ulceration  in  the  form  of  lupus  has  already  been  described 
(p.  247). 

Malignant  ulceration,  common  about  the  nose  of  the  elderly,  begins 
as  an  indolent,  persistent,  scabbing,  superficial  ulcer,  the  true  nature  of 
which  can  be  detected  at  a  serviceable  time  only  by  excision  and 
examination. 

Elephantiasis. — Elephantiasis  exhibits  a  predilection  for  the  nose,  pro- 
ducing hideous  disfigurement. 

Affections  of  the  Mucous  Membrane  Characterized  by  the  Rapid 
Onset  (Hours  or  Days)  of  Inflammatory  Symptoms. — Acute  Rhinitis 
(Coryza). — Commonly  attributed  to  exposure  to  cold,  it  is  usually 
an  expression  of  a  toxemic  condition  (measles,  tj^hoid,  etc.),  or  of  a 
reaction  against  an  irritant,  such  as  pollen  (rose  cold,  etc.),  or  bacteria. 

It  is  characterized  by  heat,  redness  and  swelling  of  the  mucous  mem- 
branes of  the  nasal  cavities,  accompanied  by  first  serous  then  muco- 
purulent dischage.  The  swelling  obstructs  nasal  breathing,  lessens  or 
entirely  suspends  the  sense  of  smell,  and  diminishes  the  acuteness  of 
the  sense  of  taste.  Tinnitus  and  dulled  hearing  are  the  expressions  of 
an  accompanying  nasopharyngeal  catarrh.  Involvement  of  the  frontal 
sinus  is  evidenced  by  dull  frontal  headache,  which  becomes  extremely 
severe  if  the  infundibulum  be  blocked,  and  is  then  subject  to  sudden 
remissions  often  preceded  by  a  bubbling  sound.  This  infection,  if 
grippal,  commonly  extends  to  all  the  nasal  mucous  surfaces  and  down- 
ward to  the  lungs,  and  is  accompanied  by  the  general  pains  and  fever  of 
septic  toxemia. 

Diphtheritic  rhinitis  is  characterized  by  the  severity  of  both  the  local 
and  constitutional  symptoms  and  the  finding  of  the  bacillus.  This 
infection  may  occur  in  the  absence  of  throat  involvement,  and  mav 
assume  a  chronic  form  with  persistent  toxemia  as  its  most  pronounced 
manifestation. 

Foreign  Bodies  and  Nasal  Calculi. — Foreign  bodies  are  characterized 
by  obstruction  of  one  fossa  and  a  unilateral,  purulent,  blood-streaked 
discharge  often  associated  with  recurring  slight  attacks  of  epistaxis. 
It  is  commonest  in  children.  Diagnosis,  suggested  by  discharge  from 
one  nostril,  is  confirmed  by  careful  examination.  A  foreign  body,  if 
18 


274  THE  HEAD,  FACE,  AND  NECK 

not  removed,  may  lie  embedded  in  a  mass  of  granulation  tissue  closely 
resembling  cancer. 

Maggots  have  been  observed  in  the  nasal  fossa. 

Nasoliths  cause  the  symptoms  of  foreign  body — with,  however,  a 
more  gradual  onset. 

Affections  Characterized  by  Chronic  Nasal  Discharge. — All 
obstructive  lesions  are  accompanied  by  chronic  rhinitis,  including 
under  this  heading  septal  deflections  or  overgrowths,  foreign  bodies, 
diseases  of  the  accessory  sinuses,  and  syphilitic  or  tuberculous  infiltration 
and  ulceration. 

Chronic  Rhinitis  .-^Chronic  rhinitis  may  be  hypertrophic  or  atrophic. 

Hypertrophic  rhinitis  is  characterized  by  mucopurulent  discharge 
and  nasal  obstruction  aggravated  by  slight  causes.  Examination  shows 
a  vascular,  freely  secreting,  sometimes  crusted,  mucous  membrane,  so 
thickened  as  to  fill  the  nasal  cavity.  The  turbinals  are  often  edema- 
tous, suggesting  the  appearance  of  a  sessile  polyp. 

Atrophic  rhinitis,  common  in  the  female,  and  to  an  extent  hereditary, 
is  characterized  by  a  sweetish,  sickening  stench  appalling  to  every- 
one but  the  patient.  The  nasal  fossse  are  unduly  roomy,  and  to  the 
atrophied  mucous  membrane  adhere  foul  crusts  which  come  away 
reluctantly,  leaving  eroded  mucous  membrane.  Syphilitic,  neoplastic, 
and  foreign  body  rhinitis  may  all  give  an  offensive  odor,  but  resemble 
atrophic  rhinitis  in  no  other  respect. 

Tertiary  Syphilis. — ^Tertiary  syphilis  in  the  form  of  gummatous  infiltra- 
tion may  rapidly  destroy  both  the  bones  and  cartilages  of  the  nose.  The 
intranasal  affection  begins  insidiously  and  painlessly.  It  is  usually  symp- 
tomless until  it  reaches  the  ulcerating  stage,  where  it  is  characterized 
by  a  discharge  which  is  peculiarly  offensive,  often  streaked  with  blood 
and  shortly  contains  fragments  of  bone  or  cartilage. 

Diagnosis  is  based  upon  profuse  offensive  discharge,  direct  examina- 
tion which  either  to  the  eye  or  to  the  probe  may  evidence  the  existence 
of  exposed  bone  or  cartilage,  and  the  history  of  preceding  syphilis 
with  the  associated  signs  of  this  affection.  Deformity  produced  by 
ulcerating  gumma  is  highly  characteristic,  nor  is  there  any  other  affec- 
tion which  can  cause  this  in  the  same  insidious  manner. 

Gummatous  infiltration  of  the  cartilaginous  septum  is  the  usual  cause 
of  perforation.  This  result  may  also  follow  abscess  or  simple  ulcer  due 
to  the  habit  of  picking  the  nose. 

Perforations  of  the  palate  are  usually  due  to  the  gumma  beginning 
on  the  nasal  aspect  of  this  bone,  and  not  appearing  as  a  swelling  on  the 
roof  of  the  mouth  until  the  bone  has  been  destroyed. 

Tuberculosis  of  the  Nose. — Usually  in  those  suffering  from  advanced 
tuberculosis  elsewhere,  has  for  its  seat  of  preference  the  cartilaginous 
septum  forming  at  this  point  usually  a  single,  irregular,  superficial, 
persistent,  chronic  ulcer  near  the  nasal  orifice.  Around  this  ulcer 
small,  semitranslucent  tubercles  are  sometimes  seen. 

A  rare  form  of  nasal  tuberculosis  occurring  in  those  without  other  signs 
of  the  disease  is  in  the  form  of  ulcerating  vegetation  also  placed  on  the 


THE  NOSE  275 

cartilaginous  septum  and  at  times  causing  perforation.  This  is  accom- 
panied by  enlargement  of  the  submaxillary  glands.  The  distinction 
from  syphilis  and  early  carcinoma  can  be  made  only  by  microscopic 
examination  of  the  exsected  tissue. 

Tumors  of  the  Nose. — Nasal  Polypi. — Nasal  polypi,  the  commonest 
tumors  of  the  nose,  constitute  jelly-like,  usually  pedunculated,  some- 
times sessile  masses,  single  or  growing  like  a  bunch  of  grapes,  and 
varying  in  size  from  that  of  a  pinhead  to  that  of  a  pigeon's  egg.  They 
usually  grow  from  the  middle  meatus  or  the  corresponding  turbinal  bone. 
Exceptionally  they  are  more  posteriorly  placed  on  the  extremities  of  the 
turbinals,  though  they  may  grow  from  the  frontal,  maxillary,  or  sphe- 
noidal sinuses. 

The  affection  is  one  of  the  adult.  It  is  characterized  by  discharge, 
obstruction,  tendency  to  bleed  slightly  on  blowing  of  the  nose,  and  loss 
of  the  sense  of  smell,  usually  unilateral  and  worse  in  damp  weather. 

When  the  polyps  reach  large  size  they  produce  pressure  distortion  or 
frog-like  expression  to  the  face.  Examination  shows  the  shining  gray, 
jelly-like,  freely  movable  masses. 

Osteoma. — Osteoma  (commonest  in  the  frontal  sinus)  may  grow  from 
any  portion  of  the  nasal  wall  or  its  accessory  cavities.  It  forms  a  hard, 
bosselated,  irregular  tumor  of  slow  growth,  which  may  be  very  slightly 
or  not  at  all  adherent  to  its  point  of  original  outgrowth.  Its  symptoms 
are  those  of  obstruction  if  it  grows  into  the  breathing  passages,  or  of 
pressure  expressed  in  the  form  of  headache,  neuralgia,  and  deformity, 
the  latter  dependent  upon  the  direction  of  growth.  Usually  manifest 
in  the  orbit  when  the  growth  is  from  the  frontal  sinus,  pushing  the  eye 
downward,  forward,  and  outward.  Osteoma  from  the  maxillary  sinus 
usually  projects  the  cheek.  The  growth  may  come  from  the  sphenoid 
or  ethmoid  sinuses.      The  diagnosis  is  based  upon  the  x-ray  picture. 

Epithelioma. — Epithelioma  attacking  the  inner  surface  of  the  nostril 
in  the  form  of  rodent  ulcer  is  characterized  by  a  slow  but  destructive 
persistence.  Syphilitic  lesions  are  all  more  rapidly  destructive,  and 
yield  promptly  to  treatment.  The  diagnosis  should  be  made,  after 
excluding  syphilis,  by  wide  removal  and  microscopic  examination. 

Sarcoma. — Sarcoma,  particularly  upon  the  septum  in  young  people, 
is  characterized  by  its  rapid  infiltrating  growth,  by  recurrent  bleedings, 
and  stinking  discharge.  The  diagnosis  should  be  made  on  excluding 
syphilis  by  wide  removal  and  microscopic  examination. 

Affections  of  the  Sinuses  Communicating  with  the  Nose. — Inflam- 
mation of  the  Maxillary  Sinus. — ^This  is  secondary  to  erysipelas  or  abscess 
of  the  face,  inflammation  of  the  mucous  membrane  of  the  nose,  or  to 
caries  of  the  teeth,  especially  the  first  and  second  molars. 

When  the  opening  from  the  antrum  into  the  middle  meatus  is  suffi- 
ciently patulous  to  prevent  tension  from  retained  secretions,  the  symptoms 
may  be  confined  to  a  profuse,  purulent,  intermittent  nasal  discharge 
running  freely  when  the  head  is  bent  well  forward,  and  turned  toward  the 
sound  side,  and  coming  from  the  middle  meatus. 

When  the  opening  into  the  nose  is  blocked,  in  addition  to  constitutional 


276  THE  HEAD,  FACE,  AND  NECK 

symptoms  there  is  severe  suborbital  pain,  often  involving  the  teeth,  rapid, 
edematous  swelling  of  the  cheek  of  the  affected  side,  obliteration  of 
the  canine  fossa,  and  shortly  (days)  crackling  on  pressure  in  this  region 
due  to  erosion  of  the  bone. 

Transillumination,  accomplished  by  an  electric  bulb  held  in  the  mouth 
with  the  lips  closed,  will  show  in  a  darkened  room  a  shadow  in  contrast 
to  the  pink  of  the  healthy  side. 

In  the  direct  examination  of  the  nasal  cavity  the  pus  is  cleared  away 
from  the  middle  meatus  and  the  patient  is  directed  to  tip  the  head  well 
forward  and  toward  the  normal  side.  A  free  flow  of  pus  from  the  middle 
meatus  is  characteristic  of  suppuration  of  the  maxillary  sinus. 

Finally,  if  other  diagnostic  means  fail,  or  in  corroboration  of  these,  a 
needle  of  large  caliber  attached  to  an  aspirating  syringe  is  passed  along 
the  inferior  meatus  to  the  depth  of  one  and  one-half  inches,  and  is  driven 
obliquely  outward  and  upward  into  the  maxillary  sinus,  which  is  then 
washed  out  with  a  boric  acid  solution. 

As  a  result  of  suppuration  of  the  maxillary  sinus,  particularly  that  due 
to  periostitis  of  dental  origin,  fistulse  may  form,  opening  into  the  face  or 
the  cavity  of  the  mouth. 

Mucous  Cysts  of  the  Sinus. — Mucous  cysts  of  the  sinus,  due,  in  part,  to 
obliteration  of  its  orifice  or  cystic  dilatation  of  its  glands,  cause  no  symp- 
toms, except  perhaps  preliminary  toothache  and  pressure  upon  the  infra- 
orbital nerve  until  their  growth  is  sufficient  to  cause  tension.  There 
then  develops  a  tumor  due  to  yielding  of  the  bony  wall  of  the  sinus  in 
all  directions.  The  thin  crackling  bone  finally  allows  fluctuation  to  be 
detected. 

Mucous  cyst  is  an  affection  of  young  people,  and  cannot  be  distinguished 
from  malignant  growth  except  by  its  slow  progression,  its  absence  of 
infiltration,  and  the  result  of  operation. 

Tumors. — ^Tumors  originating  in  the  maxillary  sinus  cannot  be  recog- 
nized until,  by  their  growth,  they  displace  or  infiltrate  the  bony  walls 
and  produce  deformity,  though  the  frequently  associated  signs  of  sinus 
suppuration  with  pain  in  the  cheek  and  teeth  may  even  early  in  their 
course  suggest  an  exploratory  operation. 

Myoma,  osteoma,  fibroma,  enchondroma,  have  all  been  observed. 
Sarcoma  is  the  commonest  malignant  tumor  starting  from  the  septum 
or  the  walls  of  the  accessory  sinuses,  and  characterized  by  rapid  progress, 
infiltration,  and  destruction  of  the  bony  envelope,  progressive  invasion  of 
the  surrounding  soft  parts,  and,  in  the  case  of  carcinoma,  early  involve- 
ment of  the  cervical  ganglia. 

In  the  carcinomatous  form  these  tumors  develop  in  people  past  middle 
life,  and  all  are  usually  characterized  by  extreme  pain. 

Both  the  benign  and  the  malignant  growths  cause  a  sense  of  weight 
and  tension  in  the  face,  swelling  of  the  cheek,  bulging  of  the  palate, 
obstruction  of  the  nasal  fossa,  exophthalmos,  and  loosening  and  falling 
of  the  teeth,  all  expressions  of  their  eroding  or  infiltrating  growth. 

Inflammation  of  the  Frontal  Sinus. — Inflammation  of  the  frontal  sinus, 
exceptionally  traumatic,  is  secondary  to  infection  of  the  mucous  mem- 


THE  NOSE  277 

brane  of  the  nose,  particularly  that  of  the  middle  meatus  or  to  syphilitic 
inflammation  of  the  surrounding  bone. 

Acute  inflammation,  with  the  infundibulum  not  entirely  occluded, 
is  characterized  by  a  nasal  discharge  and  dull  pain  in  the  forehead  and 
at  the  root  of  the  nose,  greatly  aggravated  by  blowing  the  nose.  When 
the  infundibulum  is  occluded,  the  pain  is  severe  and  may  be  agonizing  in 
its  intensity,  tenderness  over  the  sinus  is  marked,  best  elicited  by  upward 
pressure  at  the  upper  inner  angle  of  the  orbit,  internal  to  the  supra-orbital 
notch,  and  there  shortly  develops  swelling  in  this  sensitive  region.  Or,  if 
the  septum  be  incomplete,  the  swelling  may  be  bilateral.  An  associated 
osteitis  and  necrosis  allows  of  pus  escape  either  into  the  nasal  cavity  or 
into  the  orbit,  causing  in  the  latter  case  exophthalmos,  orbital  swelling, 
and  usually  the  presence  of  a  fluctuating  tumor. 

The  diagnosis  of  acute  sinusitis  with  obstruction  is  obvious. 

Chronic  empyema  of  the  sinus  gives  a  free  discharge  of  pus  on  rising 
in  the  morning,  a  dull  shadow  on  transillumination,  usually  frontal 
headache,  often  most  severe  in  the  morning  and  subsiding  at  night, 
much  aggravated  by  intercurrent  attacks  of  nasal  catarrh  and  relieved 
by  free  discharge,  and  supra-orbital  tenderness  and  neuralgia.  A  positive 
diagnosis  can  be  made  by  catheterizing  the  infundibulum.  This  is 
often  not  practicable  until  a  portion  of  the  midturbinal  has  been  excised. 
Direct  examination  shows  the  discharge  coming  from  the  middle  meatus. 
The  x-rays  and  transillumination  are  helpful,  at  times  diagnostic.  Men- 
ingitis, brain  abscess,  and  sinus  thrombosis  are  occasional  sequelae. 

Tenderness  of  supra-orbital  neuralgia  is  most  marked  over  the  nerve 
trunk,  that  of  frontal  sinus  disease  within  this  point. 

Tumors. — Tumors  of  the  frontal  sinus  cannot  be  detected  until  they 
cause  marked  deformity  usually  of  the  upper  inner  orbital  wall. 

Inflammation  of  the  Sphenoidal  Sinus. — Inflammation  of  the  sphenoidal 
sinus,  secondary  to  rhinitis,  particularly  that  incident  to  la  grippe,  polyp, 
and  syphilitic  necrosis  of  the  body  of  the  sphenoid,  is  characterized  by 
purulent  nasal  discharge,  headache,  often  referred  to  the  occiput  or  the 
region  of  the  mastoid,  at  times  by  lacrymation,  blepharospasm,  photo- 
phobia, and  optic  neuritis.  The  pus  runs  back  into  the  pharynx,  and, 
being  moderate  in  quantity,  crusts  in  this  position.  Meningitis,  cerebral 
abscess,  thrombosis  of  the  cavernous  sinus,  orbital  phlegmon,  amaurosis, 
fatal  hemorrhage,  and  retropharyngeal  abscess  are  complications. 

Inflammation  of  the  Ethmoid  Cells. — Inflammation  of  the  ethmoid 
cells  secondary  to  nasal  infection  is  characterized  by  escape  of  pus  from 
the  middle  meatus  if  the  anterior  group  be  involved,  from  the  superior 
meatus  if  it  comes  from  the  posterior  group.  There  is  severe  pain  felt 
behind  the  globe  of  the  eye,  greatly  aggravated  by  pressure  upon  the 
base  of  the  nasal  bones,  and  a  condition  of  chronic  sepsis.  Necrosis  is 
a  common  accompaniment,  with  intracranial  complications. 

Diagnosis  is  based  upon  exclusion  of  involvement  of  the  larger  sinuses, 
and  particularly  the  detection  of  dead  bone  by  means  of  a  probe. 


278 


THE  HEAD,  FACE,  AND  NECK 


THE  NASOPHARYNX. 

The  injflammatory  affections  of  the  nasopharynx  are  those  of  the  nose. 
In  addition,  it  is  subject  to  adenoid  and  fibromatous  growth. 

Adenoid  Growth. — ^Adenoid  growth  is  particularly  common  in  catarrhal 
children  with  big  tonsils  and  enlarged  glands  of  the  neck.  Heredity 
is  a  predisposing  factor. 

The  characteristic  symptoms  are  mouth  breathing,  which  may  be 
of  immediate  serious  moment  in  an  infant,  snoring,  and  difficulty  in 
articulating  the  nasal  consonants  and  their  combinations.  Children 
thus  afflicted  sweat  easily  and  have  a  stupid  apathetic  expression.  The 
flaccid  lower  jaw,  always  swung  open,  and  the  short  upper  lip  exposing 
the  incisor  teeth  are  characteristic.  The  ears  are  often  affected  from 
the  associated  nasopharyngeal  catarrh. 


Fig.  99 


Anteroposterior  section  of  the  head  of  an  adult,  showing  the  situation  and  gross  structure  of 
hypertrophy  of  the  lymphoid  tissue  of  the  nasopharynx.     (Zuckerkandl.) 


If  the  turbinals  be  not  enlarged  these  adenoids  can  be  seen  by  anterior 
rhinoscopy;  usually  the  posterior  examination  will  be  necessary,  or,  if 
this  be  resisted,  the  diagnosis  can  be  made  by  digital  examination,  though 
in  well-marked  cases  an  immobile  palate  pushed  well  forward  will  demon- 
strate the  presence  of  growth  behind  it. 

Nasopharjmgeal  Fibroma. — ^This  grows  usually  from  the  basilar  surface 
of  the  occipital  bones  of  males  between  the  fifteenth  and  twenty-second 


THE  LIPS  279 

years.  This  age  limit  does  not  obtain  in  the  few  cases  observed  in  the 
female.  It  may  also  grow  from  the  internal  pterygoid  plate  or  from  the 
upper  cervical  vertebrae.  The  symptoms  are  those  of  nasopharyngeal 
tumor,  i.  e.,  obstruction  to  breathing,  loss  of  taste,  often  headache,  and 
mucous  discharge  from  the  nasopharynx.  The  examination  at  this 
stage  will  usually  show  the  palate  depressed  and  the  whole  nasopharynx 
filled  with  a  red,  nodular,  hard,  highly  vascular,  slightly  movable  growth, 
bleeding  readily  on  examination.  The  growth  is  slowly  progressive 
(years),  displaces  and  erodes  the  bones,  and  invades  all  the  neighboring 
cavities,  producing  exophthalmos  and  hideous  deformity  and  ultimately 
signs  of  intracranial  pressure. 

From  malignant  infiltration  the  affection  is  characterized  by  mobility, 
its  comparatively  slow  growth,  absence  of  ganglionic  enlargement  and  its 
density  of  structure.  It  pushes  all  before  it  and  destroys  by  pressure, 
but  does  not  infiltrate.  These  tumors  in  some  cases  are  fibrosarcomata. 
In  the  pure  fibromata  a  recessional  tendency  has  been  observed  after 
the  twenty-fifth  year. 

Angioma. — Angioma  has  been  observed  as  a  rounded,  smooth,  dark- 
blue,  elastic  tumor,  bleeding  readily  and  freely. 

Chondroma. — Chondromata  (rare),  characterized  by  their  cartilaginous 
hardness,  grow  slowly  from  the  cartilages  and  are  prone  to  recur  after 
removal.     They  are  usually  mixed  tumors. 


THE  LIPS. 

Acute  Inflammatory  Affections.- — One  or  both  lips  may  become  suddenly 
hot  and  swollen  without  obvious  cause  as  an  expression  of  urticaria. 

Herpes  in  the  form  of  fever  blisters,  which,  if  numerous,  are  accom- 
panied by  distinct  swelling,  is  a  frequent  accompaniment  of  gastro- 
intestinal disturbance  and  may  form  by  confluence  one  or  more  thick, 
black  crusts,  strongly  suggesting  chancre.  The  herpetic  ulcerations 
should  last  a  week  at  the  most,  and  appear  first  as  vesicles. 

The  crusted  lesions  of  impetigo  contagiosa  are  common  about  the 
lips.     Their  sudden  development  and  brief  course  are  characteristic. 

Ulcerations. — A  simple  ulcer,  weather  crack,  or  traumatic  fissure  of  the 
lips  may  persist  for  weeks,  getting  almost  well,  then  recurring.  There 
is,  however,  always  a  tendency  toward  progressive  betterment.  When 
the  lesion  occurs  on  the  lower  lip  of  a  middle-aged  man,  and  in  the  course 
of  weeks  slowly  grows  worse,  the  diagnosis  of  its  benignancy  should  be 
made  by  excision. 

Chancre. — Chancre,  characterized  by  the  development  (days)  of  a 
raised  indurated  ulcer,  externally  crusted,  exhibiting  a  dirty  white, 
closely  adherent  pseudomembrane  on  the  mucous  surface  and  causing 
disfiguring  swelling  of  the  entire  lip  and  early  adenopathy,  may  be  mis- 
taken for  a  simple  fissure  or  a  cancer.  No  simple  ulcerative  lesion 
develops  without  obvious  cause  nor  does  it  progressively  increase  in  size. 
Cancer  is  much  slower  in  development  (months). 


280 


THE  HEAD,  FACE,  AND  NECK 


Mucous  Patches. — Mucous  patches  on  the  inner  surface  of  the  Kps 
and  the  corners  of  the  mouth  are  extremely  common.  The  distinction 
from  aphthae  is  made  by  their  association  with  other  signs  of  syphiHs. 
In  children  syphilitic  ulceration  is  often  deep  enough  about  the  corners 
of  the  mouth  to  be  followed  by  radiating  cicatrices  which  form  character- 
istic remnants  of  this  disease. 

Gumma. — Gumma  of  the  lips  is  rare.  When  it  occurs  it  exhibits 
the  features  of  this  affection  as  seen  on  other  mucous  surfaces. 

Tumors  of  the  Lips.— Epithelioma. — Epithelioma  usually  begins 
at  the  mucocutaneous  junction,  sometimes  on  the  mucous  surface  of  the 
lower  lip  of  middle-aged  or  old  men.  Exceptionally  it  is  seen  in  young 
men,  in  women,  and  on  the  upper  lip. 

The  diagnosis  should  be  made  by  examination  of  the  excised  lesion 
when  it  is  apparently  a  simple  chronic  induration,  persistent  fissure,  or 
erosion,  or  an  inflamed  scabbing  papilloma. 

Fig.  100 


Lymphangioma  and  hemangioma   of   the   lip  and  cheek.     A  soft,  bluish  tumor  exhibiting  shot- 
like nodules  due  to  phleboliths.     Markedly  increased  in  size  by  venous  congestion  of  the  head. 


Infiltration,  fungous  outgrowth,  rapid  extension  and  involvement  of 
lymphatics  make  the  diagnosis  absolute  and  futile.  Early  glandular 
enlargement  should  be  detected  by  bimanual  palpation,  the  finger 
of  one  hand  being  placed  on  the  mucous  membrane  of  the  floor  of  the 
mouth,  but  the  diagnosis  should  not  be  kept  in  abeyance  until  this  sign 
develops. 

Hypertrophied  labial  glands,  either  congenital  or  acquired,  may  cause 
a  roll  of  mucous  membrane,  producing  the  appearance  of  a  double  lip, 


PLATE   XV 


Epithelioma  of  the  Lip.      (Griinwald.) 


THE  JAWS 


281 


most  perceptible  when  the  upper  lip  is  retracted  as  in  laughing,  sometimes 
large  enough  to  form  a  projecting  mass  simulating  cancer. 

Angiomata,  both  venous  and  arterial,  producing  great  enlargement  of 
the  lips,  are  observed  in  this  region.  They  are  often  associated  with 
lymphangioma  producing  a  condition  of  deforming  hypertrophy  called 
macrocheilia.  The  lymphangioma  is  usually  present  at  birth,  but 
may  not  constitute  a  distinct  deformity  until  puberty  or  afterward. 

Lipoma  is  shown  by  its  soft  consistence  and  yellow  color.  It  is  often 
associated  with  angioma. 

Adenomata  appear  as  small,  hard  tumors,  single  or  multiple,  placed 
just  beneath  the  mucous  membrane. 

Fig.  101 


Mucous  cyst  of  the  lip.     Duration,  months.     Opened    twice,    discharging    a  viscid,  clear  mucus. 
Soft,  translucent,  painless,  non-inflammatory.     (Hoban.) 

Cysts  of  the  labial  salivary  glands  form  small,  semitranslucent,  rounded, 
non-inflammatory  tumors  placed  beneath  the  mucous  membrane. 

Mixed  tumors  sometimes  develop  in  this  region  and  are  characterized 
by  their  rapid  growth  and  large  size. 


THE  JAWS. 


Fractures. — Fracture  of  the  upper  jaw,  due  to  direct  violence,  usually 
involves  the  alveolar  border.  Transverse  fracture,  or  detachment  of 
the  vault  of  the  mouth  with  the  teeth,  is  characterized  by  deformity  and 
unnatural  mobility  of  the  entire  dental  arch  and  crepitus. 

Guerin  states  that  tenderness  and  mobility  elicited  by  pressure  upon 
the  inner  pharyngeal  plate  are  almost  diagnostic  of  this  fracture. 

Fracture  of  the  lower  jaw,  usually  in  adults,  is  commonest  at  about 
the  position  of  the  mental  foramen  and  is  usually  oblique.     It  may 


282 


THE  HEAD,  FACE,  AND  NECK 


be  multiple  or  fissured.  The  condyloid  process  is  not  an  unusual  seat 
of  this  injury. 

Fracture  of  the  body  of  the  jaw  is  usually  attended  by  a  deflection  of 
the  chin  toward  the  affected  side  and  by  a  marked  irregularity  in  the 
line  of  the  teeth.  The  anterior  portion  of  the  bone  is  pulled  downward 
and  backward.  The  mucous  membrane  will  be  found  torn  at  the  point 
where  the  dental  arch  is  broken  and  crepitus  and  preternatural  mobility 
are  readily  elicited. 

To  elicit  mobility  and  crepitus  the  jaw  is  grasped  with  the  thumb 
placed  behind  the  dental  arch  and  the  fingers  beneath  the  body.  The 
two  hands  are  used,  one  holding  each  fragment,  the  surgeon  standing 
behind  the  patient,  who  is  seated.  A  break  in  the  continuity  can  often 
be  detected  by  external  palpation  alone. 

Fractures  of  the  ramus,  attended  with  little  deformity,  may  be  detected 
by  combined  internal  and  external  palpation.  Persistent  pain  on  use  and 
deep,  fixed,  localized  tenderness  on  palpation  may  be  the  only  symptoms. 

Fractures  of  the  coronoid  process  are  characterized  by  tenderness, 
slight  anterior  displacement  of  the  condyle,  swelling,  and  crepitus  felt 
immediately  beneath  the  finger,  and  by  great  pain  consequent  upon  every 
motion  of  the  joint. 


Fig.  102^ 


Fig.  103 


Fig.  102. — Fracture  of  lower  jaw,  through  anterior  portion  of  body,  in  region  of  canine  fos.sa. 
(Somewhat  anterior  to  the  more  common  seat — see  Fig.  103.)  Patient  an  adult  male.  Note  the 
typical  deformity — downward  displacement  of  the  anterior  fragment  and  elevation  of  the  posterior 
portion. 

Fig.  103. — Fracture  of  lower  jaw,  comminuted,  at  about  middle  of  lateral  aspect  of  body.  (A 
very  common  seat  of  fracture.)  Note  the  angvdar  deformity  and  slight  over-riding,  the  loose  frag- 
ment, and  the  atrophy  of  the  alveolar  border  in  conformity  with  the  age  of  the  patient — a  female, 
aged  sixty-eight  years — and  following  the  loss  of  the  teeth. 


1  Figs.  102  to  105.  Fractures  of  the  head  and  neck.  Outline  drawings  from  radiographs  by  Dr. 
H.  K.  Pancoast  in  collection  of  University  Hospital  a-ray  Laboratory;  patients  referred  by  or 
from  services  of  Drs.  White,  Martin,  and  Carnett,  and  from  dispensaries,  and  private  cases  of  Dr. 
Pancoast. 


THE  JAWS 

Fig.  104 


283 


Fracture  of  lower  jaw  slightly  in  front  of  angle.  (A  frequent  seat  of  fracture,  but  less  common 
than  farther  forward.)  Fracture  fissured  and  line  oblique  and  involving  socket  oif  second  molar 
tooth.     There  is  neither  separation  nor  displacement.     Male,  aged  twenty-two  years. 


Fig.  105 


(a)  Fracture  of  the  coronoid  process  of  the  lower  jaw,  with  separation  and  upward  displace- 
ment of  the  fragment  by  the  temporal  muscle.  (6)  Multiple  fracture  of  the  zygoma  of  the 
same  side.  The  lines  of  fracture,  indicated  by  arrows,  are  posteriorly  near  the  root  of  the 
process  and  anteriorly  near  its  jimction  with  the  malar  bone.  There  is  no  displacement  vertically, 
but  depression  would  not  be  indicated  in  this  view,  although  it  could  be  shown  in  an  anteroposterior 
picture.     The  injury  was  due  to  direct  violence.     Patient  a  young  adult  male. 


284  THE  HEAD,  FACE,  AND  NECK 

Inflammation  of  the  Jaws.^ — Diffuse  osteomyelitis  of  the  jaw  may 
be  either  acute,  subacute,  or  chronic. 

Acute  Osteomyelitis. — Acute  osteomyelitis  may  be  secondary  to  trau- 
matism, to  exanthemata  and  other  systemic  infections,  or  may  develop 
suddenly  without  ascertainable  cause.  It  occurs  in  young  people  about 
the  time  of  puberty.  The  eruption  of  a  wisdom  tooth  has  seemed  to 
be  a  predisposing  factor.  The  infection,  commonest  in  the  lower  jaw, 
may  involve  a  part  or  all  of  the  bone,  producing  rapid  and  complete 
necrosis.  It  is  characterized  by  intense  pain,  rapid  edematous  swelling, 
symptoms  of  profound  toxemia,  and  loosening  of  the  teeth  with  escape 
of  pus  from  their  sockets. 

The  prognosis  is  grave  in  proportion  to  the  amount  of  bone  involved. 

Acute  Osteoperiostitis. — Acute  osteoperiostitis,  usually  secondary  to 
dental  caries,  is  characterized  by  severe  pain,  local  tenderness,  and 
swelling  associated  with  pronounced  edema  of  the  cheek.  The  resultant 
abscess  usually  develops  as  a  gumboil  discharging  into  the  mouth.  It 
may  open  externally,  forming  a  sinus  communicating  with  dead  bone. 
Exceptionally  the  infection  reaches  the  deep  tissues  of  the  neck  and 
spreads  rapidly  through  them,  causing  brawny  infiltration  and  symptoms 
of  profound  sepsis. 

Occupation  osteoperiostitis  and  necrosis  are  observed  in  those  working 
in  phosphorus,  arsenic,  mercury,  and  mother-of-pearl.  Phosphorus 
osteitis,  slow  in  progression  and  beginning  with  a  toothache,  results 
in  necrosis  characterized  by  foul  discharge  of  pus  from  the  sides  of  the 
teeth. 

Arsenical  osteitis  is  characterized  by  its  more  rapid  course. 

Mercurial  osteitis  begins  as  a  suppurative  gingivitis,  and  is  not  usually 
attended  by  wide  destruction  of  bone. 

Pearl-grinder's  osteitis,  developing  at  the  age  of  puberty,  is  character- 
ized by  severe  pain  and  swelling  at  the  junction  of  the  epiphysis  and 
diaphysis. 

Osteoperiosteitis  may  be  of  the  formative  type,  resulting  in  great  thick- 
ening of  the  bone  with  consequent  deformity. 

Syphilis  of  the  Jaw. — Syphilis  of  the  jaw  is  characterized  by  the  forma- 
tion of  periosteal  gummata,  which  may  result  in  permanent  exostoses. 
Gummata  are  particularly  common  on  the  hard  and  soft  palate,  and 
are  the  usual  causes  of  perforation.  Diagnosis  is  based  upon  the  history 
of  the  case  and  the  results  of  treatment. 

Tuberculosis. — Tuberculosis  of  the  maxillary  bones  may  appear  in 
the  form  of  chronic  alveolar  abscess  in  patients  suffering  from  pulmon- 
ary tuberculosis.  The  diagnosis  is  usually  made  by  the  microscope. 
Primary  tuberculosis  of  the  lower  jaw  is  marked  by  an  indurated 
swelling,  attended  with  little  pain,  sometimes  by  stiffness  of  the  jaw. 
Necrosis  and  fistulization  follow,  together  with  cervical  glandular  enlarge- 
ment. The  disease  is  slow  in  progression  (years),  and  the  diagnosis  is 
made  by  the  x-rays  and  the  tuberculin  test.  Distinction  from  sarcoma 
may  require  an  exploratory  operation.  Sarcoma  is  more  rapid  in  pro- 
gression, and  does  not  involve  the  lymph  glands,  nor  does  actinomycosis. 


THE  JAWS  285 

Actinomycosis.- — Actinomycosis  of  the  jaw,  usually  due  to  an  extension 
from  the  gums,  is  characterized  by  hard,  nodulated  infiltration  of  both 
the  soft  parts  and  the  bone,  exhibiting  a  tendency  to  multiple  sinus  forma- 
tion and  slow  (months,  years)  but  steady  extension.  In  its  beginning 
the  disease  is  evidenced  by  an  alveolar  abscess  differing  from  those 
incident  to  ordinary  infection  only  from  the  fact  of  its  persistence  and 
extension  to  both  the  soft  parts  and  the  bone.  Affection  of  the  upper 
jaw  is  characterized  by  more  rapid  extension,  loosening  of  the  teeth, 
and  early  involvement  of  the  antrum. 

The  diagnosis  is  based  upon  multiple  sinus  formation,  the  presence  of 
the  yellow  granules  in  the  pus,  and  the  detection  under  the  microscope 
of  the  characteristic  fungus.  When  these  are  not  found,  cultures  may 
be  needful. 

Tumors  of  the  Jaw. — Epulis. — Epulis  forms  a  red,  easily  bleeding, 
irregularly  lobulated  tumor,  growing  from  the  gum  or  the  alveolar  border 
between  the  teeth.  It  may  be  fibromatous  or  sarcomatous  in  nature, 
as  it  appears  in  the  young,  or  carcinomatous  in  the  middle-aged  and 
elderly.     Diagnosis  should  be  made  by  complete  excision. 

Fibroma. — Fibroma,  commonest  in  the  upper  jaw,  forms  a  dense  tumor 
characterized  by  indolence,  lack  of  infiltration,  and  absence  of  glandular 
involvement.  Developing  from  the  interior  of  the  bone  it  can  be  dis- 
tinguished from  malignant  infiltration  only  by  the  extreme  slowness  of 
its  progress. 

The  diagnosis  from  sarcoma  should  be  made  by  excision. 

Chondroma. — ^Chondroma  is  characterized  by  nodular  tumor  of  almost 
bony  hardness,  extremely  slow  in  progression,  and  unattended  by  inflam- 
matory symptoms.  It  is  essentially  an  affection  of  early  maturity.  The 
growth  may  take  place  into  the  maxillary  sinus  or  from  the  nasal  process 
into  the  nasal  chambers.     The  diagnosis  should  be  made  by  excision. 

Osteoma. — Osteoma,  when  situated  on  the  surface,  is  characterized  by 
extreme  density  and  slow  growth.  Exceptionally,  the  growth  is  rapid 
and  can  then  be  distinguished  from  sarcoma  only  by  operation. 

Odontoma. — Odontoma,  dependent  upon  perverted  tooth  growth,  is 
seen  at  an  age  before  the  teeth  reach  their  complete  development. 
It  may  be  soft  and  cystic,  fibrous  or  eburnated.  It  is  extremely  slow 
in  growth  (years),  unattended  by  pain,  and  exhibits  a  nodular  or  bossel- 
ated  surface  involving  the  alveolus, and  projecting  on' both  the  outer 
and  inner  surface  of  the  jaw.  The  distinction  from  malignant  growths 
should  be  made  by  prompt  excision. 

Dentigerous  Cyst. — Dentigerous  cyst,  due  to  the  retention  of  a  tooth 
within  its  follicle,  is  characterized  by  a  somewhat  sharply  circumscribed 
swelling,  usually  of  the  lower  jaw,  extremely  slow  in  growth  (years), 
and  projecting  externally.  Its  growth  is  most  obvious  at  or  after  the 
time  of  second  dentition.  The  cyst  may  break  through  the  bone,  form- 
ing a  tumor  of  considerable  size.  The  diagnosis  will  be  suggested  by 
the  absence  of  a  tooth  not  otherwise  accounted  for,  by  the  x-rays,  and 
by  exploratory  operation.  Similar  cysts,  unilocular  or  racemose,  may 
develop  in  connection  with  a  carious  tooth. 


286 


THE  HEAD,  FACE,  AND  NECK 


Sarcoma. — Sarcoma,  commonest  in  the  young,  may  appear  in  any  of 
its  forms,  usually  growing  from  the  alveolar  processes  about  the  incisor 
or  canine  teeth  in  the  form  of  epulis.  Arising  from  the  upper  jaw,  it 
exhibits  a  marked  tendency  to  grow  into  the  maxillary  sinus,  nose,  orbit, 
pharynx,  and  base  of  the  skull.  In  the  beginning  of  its  development 
sarcoma  cannot  be  distinguished  from  fibroma.  Its  rapid  growth  should 
suggest  diagnosis.  The  variety  which  begins  within  the  bone  substance 
is  characterized  by  persistent  pain  and  localized  tenderness.  When 
the  tumor  thins  the  bone  and  breaks  externally  into  the  soft  parts,  the' 
diagnosis  is  not  difficult. 

Fig.  106 


Osteosarcoma  of  maxillary  sinus.     Dense,  hard  swelling.      Four  months'  duration.     Skin 
normal.     Bulging  of  hard  palate.     No  glandular  involvement.     (Carnett.) 


Carcinoma. — Carcinoma,  an  affection  of  old  age,  may  be  primary  in 
the  bones  of  the  jaw  or  secondary  to  lesions  of  the  surrounding  glandular 
structures.  The  affection  is  characterized  by  pain,  which  remains  fixed 
and  is  often  most  severe.  Because  of  the  comparatively  rapid  growth 
(weeks  or  months)  pressure  symptoms  shortly  develop.  In  the  case  of 
the  upper  jaw  the  nostril  of  the  affected  side  becomes  blocked,  there  is 
swelling  of  the  corresponding  side  of  the  face,  and  the  tumor  shortly 
erodes'  the  palate.  Exophthalmos  and  fixation  of  the  eye  are  compara- 
tively early.  Cancer  of  the  lower  jaw  occasions  an  earlier  involvement 
of  the  cervical  lymph  glands  than  does  that  of  the  upper  jaw. 


THE  JAWS  287 

The  Temporomaxillaiy  Articulation. — The  temporomaxillary  articu- 
lation allows  of  both  a  hinge  and  a  gliding  motion,  facilitated  by  inter- 
position of  an  interarticular  cartilage,  provided  on  its  upper  and  the 
lower  surface  with  an  independent  synovial  sac. 

Sprains. — Sprains  of  the  temporomaxillary  joint  are  expressed  in  the 
form  of  local  tenderness  and  pain  on  forceful  movements.  As  the 
result  of  sprain  or  overuse,  or  without  obvious  cause,  there  may  develop 
a  noisy  joint  in  the  form  of  a  soft  or  rough  crepitus  on  motion.  This 
condition  is  often  not  attended  wath  pain,  disability,  or  the  subsequent 
manifestations  of  deforming  arthritis. 

Luxation  of  the  Lower  Jaw. — The  unilateral  or  bilateral  dislocation, 
intracapsular  and  always  forward,  may  be  incident  to  the  muscular 
exertion  of  opening  the  mouth  widely,  to  traumatism,  producing  the 
same  effect,  or  to  force  exerted  from  behind  when  the  mouth  is  open. 

It  is  characterized  by  fixation  of  the  jaw  with  the  mouth  partly  open 
and  the  chin  preternaturally  prominent  and  great  pain  felt  in  the  temporo- 
maxillary articulation.  A  hollow  can  be  felt  directly  in  front  of  the 
tragus  in  the  normal  position  of  the  head  of  the  bone.  In  front  of  this 
will  be  found  the  projection  formed  by  its  displacement.  In  unilateral 
displacement  the  jaw  is  deflected  away  from  the  injured  side.  In  either 
unilateral  or  bilateral  displacement  the  lower  dental  arch  projects  beyond 
the  upper. 

Recurring  subluxation  incident  to  a  preternaturally  mobile  inter- 
articular cartilage  is  attended  with  a  sharp  click  or  jar  when  the  mouth 
is  opened  widely;  at  times  by  pain  and  fixation  readily  relieved.  The 
condyle  is  not  displaced  forward  beyond  its  physiological  limit.  Many 
people  can  voluntarily  produce  subluxation  without  experiencing  pain 
or  subsequent  discomfort. 

Acute  Arthritis. — Acute  arthritis,  commonly  secondary  to  external 
otitis,  suppurative  parotiditis,  or  osteomyelitis  of  the  inferior  maxilla, 
may  be  gonorrheal,  rheumatic  or  a  local  expression  of  the  infection  or 
toxemia  of  the  exanthemata.  The  symptoms  are  those  common  to  joint 
inflammation.  The  jaw  is  held  slightly  open  and  projecting;  any  move- 
ment causes  severe  pain.  In  suppurative  cases  the  pus  has  a  tendency 
to  burrow  toward  the  surface  of  the  cheek  through  either  the  skin  over- 
lying the  joint  or  the  external  auditory  meatus. 

The  pyogenic  and  gonococcal  infections  often  terminate  in  ankylosis. 
The  rheumatic  arthritis  usually  undergoes  resolution  without  subsequent 
stiffness. 

Tuberculous  Arthritis. — Tuberculous  arthritis  is  extremely  rare.  Pain 
and  limitation  of  motion  in  the  temporomaxillary  joint,  with  a  slow,  non- 
inflammatory swelling  exhibiting  an  ultimate  tendency  to  soften  and 
form  sinuses  are  the  characteristic  features  of  the  affection. 

Chronic  Osteoarthritis. — Chronic  osteoarthritis,  characterized  by  crepi- 
tation in  the  joint  on  forceful  movements,  and  often  recurring  subacute 
attacks  of  tenderness  and  pain,  ultimately  exhibits  the  obvious  and  crip- 
pling deformities  of  this  condition. 

Fixation  of  the  Jaw. — This  may  be  of  muscular,  fibrous,  or  bony  origin. 


288  THE  HEAD,  FACE,  AND  NECK 

Muscular  fixation  in  its  temporary  form  may  be  an  expression  of 
hysteria  or  of  central  irritation,  as  in  tetanus  and  trismus.  It  is  usually 
due  to  inflammation  of  the  jaw,  its  joint,  or  the  structures  about  it.  Osteo- 
periostitis and  osteomyelitis  in  either  their  acute  or  chronic  form  are  the 
common  causes.  It  is  a  typical  symptom  of  the  eruption  of  the  wisdom 
teeth  and  accompanies  mumps  or  other  parotid  inflammation.  The  con- 
traction may  be  reflex  or  due  to  direct  extension  of  inflammation.  In 
the  latter  case  the  inflammation,  if  it  be  long  continued,  may  result  in 
permanent  contracture. 

The  fixation  due  to  cicatricial  contracture  incident  to  extensive 
destruction  of  soft  parts  is  evidenced  by  the  scars. 

The  fixation  incident  to  joint  lesions  may  be  fibrous  or  bony  and  is 
usually  accompanied  by  contracture  of  the  muscles.  Joint  lesions  of 
the  growing  period  may  be  followed  by  imperfect  bone  development 
characterized  by  receding  chin.  The  distinction  between  the  fixation 
incident  to  a  contractured  muscle  and  that  due  to  fibrous  or  bony 
ankylosis  of  joint  origin  is  dependent  upon  the  history,  the  x-ray  findings, 
and  examination  under  ether. 

THE  MOUTH. 

Inflammatory  lesions  of  the  mucous  membrane,  if  multiple  and  super- 
ficial, are  usually  thrush  or  aphthae.  Occasionally  they  are  syphilitic. 
The  usual  cause  of  stomatitis  is  defective  or  erupting  teeth.  In  its  ulcero- 
membranous and  gangrenous  forms  it  attacks  the  cachectic,  following 
certain  of  the  exanthemata.  The  chronic  ulcers  of  the  mouth  are  usually 
syphilitic  or  malignant.     The  usual  tumors  are  of  the  same  nature. 

Thrush. — Thrush,  an  affection  of  young  infants,  is  characterized  by 
stomatitis,  associated  with  diffuse,  dirty  white,  superficial  patches  of 
pseudomembrane,  in  which  can  be  found  the  oidium  albicans. 

Aphthse. — x^phthae  appear  in  the  form  of  one  or  multiple  superficial, 
painful,  tender  ulcerations  presenting  either  a  red  granulating,  or  gray, 
pseudomembranous  surface.  Their  rapid  development,  usually  in  the 
course  of  some  febrile  or  digestive  disturbance,  and  prompt  subsidence 
(days)  as  the  result  of  cleansing  and  stimulating  treatment,  distinguish 
them  from  mucous  patches,  which  in  appearance  they  may  exactly 
resemble.  Recurring  single  aphthous  ulcers  are  common  in  nursing 
mothers. 

Mucous  Patches. — ]\Iucous  patches  resemble  aphthse  and  are  distin- 
guished from  the  latter  by  the  history  of  the  case,  associated  signs  of 
syphilis,  and  resistance  to  cleansing  treatment. 

Stomatitis. — Stomatitis,  secondary  to  eruption  of  the  teeth,  is  character- 
ized by  heat,  redness,  and  swelling  of  the  mucous  membrane,  particularly 
that  of  the  gums,  together  with  profuse  salivation.  In  a  localized  form 
it  may  precede  and  accompany  the  appearance  of  the  wisdom  teeth  or 
dental  caries. 

Mercurial  stomatitis  is  characterized  by  metallic  taste,  foul  breath, 
profuse  salivation,  swelling  and  bleeding  of  the  gums,  and  multiple, 


THE  TEETH  289 

superficial  ulcerations  of  the  mucous  membrane  appearing  as  gray 
patches.  There  is  often  severe  toothache.  The  submaxillary  glands 
are  enlarged  and  necrosis  is  a  common  sequel.  Diagnosis  is  based  upon 
the  history  of  the  case,  the  local  appearance,  and  the  finding  of  mercury 
in  the  urine  and  the  saliva. 

Ulceromembranous  stomatitis  is  characterized  by  the  formation  of  an 
edematous,  non-indurated,  superficial,  pseudomembranous  ulceration, 
usually  on  the  inner  surface  of  the  left  cheek  and  gums  of  ill-nourished 
children  and  young  adults,  accompanied  by  enlargement  of  the  sub- 
maxillary lymphatic  glands.  The  affection  may  spread  to  the  tongue 
or  the  palate.  Exceptionally  it  causes  alveolar  necrosis  and  shedding 
of  the  teeth.  It  is  distinguished  from  gangrenous  stomatitis  by  its 
more  benign  course. 

GangrenotLS  stomatitis  (noma)  is  an  affection  of  infancy,  common 
after  measles,  sometimes  following  diphtheria,  w^hooping-cough,  or 
scarlet  fever,  and  is  an  expression  of  profound  dyscrasia.  It  usually 
begins  as  a  hard,  gray,  ragged  ulcer  in  the  middle  of  the  mucous  surface 
of  the  cheek,  and  promptly  indurates  its  entire  thickness,  causing  a 
dusky  discoloration  of  the  skin  surface.  Septic  symptoms  and  rapid, 
deep,  and  widespread  sloughing  are  characteristic.  It  is  distinguished 
from  ulceromembranous  stomatitis  by  its  rapidly  destructive  progress, 
greater  induration,  more  extensive  edematous  swelling,  and  the  more 
pronounced  constitutional  symptoms.  It  usually  causes  shedding  of 
teeth  and  necrosis  of  bone. 

Mechanical  ulcers  on  the  cheeks  are  fairly  frequent  as  the  result  of 
sharp  or  irregular  teeth. 

Mucous  patches  and  psoriasis  are  very  commonly  placed  on  the 
inner  surface  of  the  cheek,  exhibiting  here  no  special  characteristics. 
Retention  cysts  of  the  mucous  glands  form  small  bluish  vesicles  which 
may  be  traumatized  by  the  teeth. 

Epithelioma. — Epithelioma  of  the  inner  surface  of  the  cheek  is  com- 
monly on  the  inner  dental  line,  often  upon  a  patch  of  leukoplakia.  It 
extends  with  extreme  rapidity. 


THE  TEETH. 

Dental  Caries. — Dental  caries,  the  usual  affection  of  the  teeth,  is 
noted  particularly  in  the  occlusional  fissures  of  the  molars  and  on  other 
surfaces  not  subject  to  attrition,  or  readily  cleansed.  It  is  in  its  gross 
form  characterized  by  obvious  discoloration,  roughening  and  softening, 
and  reaches  the  maximum  of  incidence  during  the  growing  period. 

The  subjective  symptoms  are  incident  to  exposure  of  the  sensitive 
dentine,  and  consist  of  transitory  pain  caused  by  sweets,  acids,  heat, 
or  cold. 

The  diagnosis  is  made  by  direct  examination,  transillumination,  and 
the  use  of  instruments  for  the  detection  of  softened  and  sensitive  surfaces 
or  cavities. 
19 


290  THE  HEAD,  FACE,  AND  NECK 

When  caries  has  extended  to  such  depth  as  to  involve  the  dental 
pulp  in  inflammation,  there  develops  a  continuous  pain  which  may 
have  its  seat  of  maximum  intensity  referred  to  any  of  the  branches  of 
the  trigeminal  nerve,  particularly  to  the  region  of  the  orbit.  This  pain 
is  increased  by  the  application  of  heat  or  cold  to  the  diseased  tooth. 

A  pulp  swollen  by  chronic  inflammation  may  grow  through  a  carious 
perforation  of  the  neck  of  a  tooth  and  closely  simulate  epulis.  The 
distinction  should  be  made  by  removal  of  the  fungating  mass  which 
will  be  found  growing  directly  from  the  tooth  cavity. 

The  symptoms  of  abscess  and  gangrene  of  the  pulp  are  those  of  root 
abscess  with  which  it  is  usually  associated,  together  with  a  loss  of  normal 
translucency  and  an  insensitive ness  to  heat  and  cold. 

Inflammation  and  Abscess  of  the  Root. — Inflammation  of  the  root  of 
a  tooth  usually  incident  to  caries  which  has  destroyed  the  pulp  without 
providing  adequate  drainage,  or  dental  procedures  which  have  accom- 
plished the  same  end,  hence  commonest  in  filled  teeth,  is  characterized 
by  severe  localized  pain,  aggravated  by  percussion  and  pressure  upon 
the  diseased  tooth.  The  gum  is  swollen  and  congested;  percussion,  if 
this  be  permissible,  gives  a  dull  note  instead  of  the  normal  resonance, 
and  the  tooth  becomes  loosened  and  slightly  extruded. 

Inflammation  may  be  due  to  traumatism,  syphilis,  gout,  intestinal 
toxemia,  or  the  injudicious  use  of  mercury  or  iodine.  If  an  abscess 
forms  it  commonly  opens  between  the  gum  and  the  neck  of  the  tooth, 
or  at  the  inner  or  outer  surface  of  the  gum  near  the  affected  root. 
There  is  often  an  alveolar  necrosis,  usually  limited  in  extent. 

In  the  absence  of  prompt  drainage  the  cheek  or  submental  region 
becomes  greatly  swollen  and  an  abscess  may  open  externally,  or  may 
cause  a  diffuse  and  fatal  form  of  cellulitis  of  the  neck. 

Severe  pain  in  the  region  of  a  tender  tooth  and  marked  edematous 
swelling  of  the  cheek  of  the  affected  side  are  the  diagnostic  symptoms. 
Developing  at  the  roots  of  the  upper  teeth,  an  abscess  may  open 
into  the  nose  (central  incisors)  or  the  maxillary  sinus  (first  and  second 
molars). 

Chronic  Abscess. — Chronic  abscess  usually  following  the  acute,  at  times 
developing  in  the  absence  of  symptoms  of  the  latter  as  an  expression  of 
deficient  drainage,  is  characterized  usually  by  few  local  symptoms  other 
than  occasional  pain  from  subacute  attacks  and  some  tenderness  on 
forceful  biting  of  a  hard  substance.  This  lesion  is  not  infrequently 
accompanied  by  the  general  toxic  or  slightly  septic  condition  expressed 
by  the  term  cryptogenic  infection. 

The  diagnosis  is  made  by  passing  a  probe  to  the  root  apex  of  a  tooth 
through  a  carious  cavity  and  finding  pus  on  the  end  of  the  probe,  or  the 
milking  by  pressure  of  a  drop  of  pus  either  from  the  space  between  the 
gum  and  the  neck  of  a  tooth  or  from  a  sinus  communicating  with  its  apex. 
These  sinuses  are  usually  associated  with  an  area  of  alveolar  caries  and 
not  infrequently  open  upon  the  cheek. 

Softening  or  complete  absorption  of  a  tooth  root  may  result  from 
apical  abscess.     Occasionally  an  extensive  osteomyelitis  develops. 


THE  TEETH  291 

Hyperplasia  of  the  Cementum. — Hyperplasia  of  the  cementum,  incident 
to  slight  trauma,  or  the  hyperemia  of  chronic  inflammation,  is  usually 
expressed  in  the  molar  roots,  appearing  in  the  form  of  a  thickened  or  dis- 
tinct nodulation.  Recurring  pain,  often  severe,  without  the  symptoms 
of  inflammation,  bettered  by  biting  hard  upon  substances,  may  be  re- 
garded as  significant  symptoms. 

This  overgrowth  is  an  occasional  underlying  cause  of  facial  neuralgia, 
and  may  be  attended  with  a  great  variety  of  neuroses.  The  diagnosis 
should  be  made  by  the  a;-rays. 

Gingivitis,  in  its  interstitial  form,  involves  both  the  gum  and  the  peri- 
cementum. It  may  be  caused  by  local  irritation,  such  as  that  incident 
to  uncleanliness,  and  the  deposit  of  calcareous  material  upon  the  teeth, 
may  be  an  expression  of  a  systemic  condition,  such  as  acute  or  chronic 
infections,  gout,  rheumatism,  intestinal  toxemia,  or  may  be  of  drug 
origin,  as  from  mercury,  iodine,  and  lead. 

The  process  is  expressed  by  swollen,  tender,  easily  bleeding  gums, 
followed  by  absorption  of  the  alveolar  process,  the  cementum,  or  both, 
and  ultimately  resulting  in  loosening  of  the  teeth. 

Salivary  Calculi. — Salivary  calculi,  appearing  in  the  form  of  soft, 
dirty  white  or  hard,  dark  deposits,  are  made  up  in  the  main  of  phosphate 
of  lime,  which  is  readily  deposited  upon  the  exposed  roots  of  teeth.  The 
outer  surfaces  of  the  upper  molars  and  both  surfaces  of  the  lower  incisors 
are  the  seats  of  preference.  These  deposits  occasion  gingivitis  and  often 
alveolar  resorption  and  recession  of  the  gums. 

Pyorrhea  Alveolaris. — Pyorrhea  alveolaris  is  predisposed  to  by  gingivitis 
and  all  conditions  which  form  pockets  which  favor  retention  and  fer- 
mentation of  food.  The  affection  is  characterized  by  calculous  deposits 
either  at  the  gum  margins  or  below  them,  upon  the  neck  and  root  of  the 
tooth,  and  purulent  discharge  which  can  be  milked  from  between  the 
gum  and  the  tooth.  In  its  further  development  the  gums  may  either 
recede,  allowing  of  comparatively  free  drainage,  or  the  pus  pockets 
may  progressively  deepen.  Ultimately  the  teeth  become  tender  and 
loosened,  the  pulp  is  inflamed  and  destroyed,  and  apical  abscesses  may 
develop.  Some  cases  are  accompanied  by  alveolar  necrosis  discharging 
by  sinus  near  the  margin  of  the  gum. 

This  condition  is  at  times  the  underlying  cause  of  profound  anemia, 
endocarditis,  and  the  joint  and  systemic  expressions  of  chronic  sepsis. 

Impacted  Teeth. — An  impacted  tooth  may  cause  severe  pain,  either  at 
the  point  of  pressure  or  referred  to  the  distribution  of  the  branches  of  the 
trigeminus.  The  lower  third  molar,  the  one  commonly  at  fault,  is  closely 
related  as  to  its  roots  with  the  proximal  portion  of  the  inferior  dental 
nerve;  when,  because  of  transverse  position,  or  because  of  absence  of 
room  between  the  second  molar  and  the  ramus  of  the  jaw,  obstruction 
is  offered  to  the  eruptive  efforts,  pain,  both  local  and  reflex,  reaches  a 
degree  of  maximum  and  crippling  intensity.  This  reflex  pain  may  be 
expressed  in  the  form  of  tic  which  may  closely  simulate  that  of  ganglion 
origin.  There  is  usually  an  associated  local  swelling,  which  may  involve 
the  whole  side  of  the  face,  and  muscular  spasm  (trismus). 


292  THE  HEAD,  FACE,  AND  NECK 

The  diagnosis  is  based  upon  the  absence  of  the  wisdom  tooth,  local 
tenderness,  and  an  x-ray  picture.  Similar  symptoms,  but  less  severe, 
may  be  characteristic  of  an  unobstructed  eruption. 

THE  TONGUE. 

The  tongue  may  be  absent  or  may  contract  vicious  adhesions,  either 
laterally  or  to  the  base  of  the  mouth. 

The  frenum  may  be  extremely  short  or  inserted  too  far  forward 
(tongue-tie).     These  conditions  are  obvious  on  inspection. 

Fig.  107 


Showing  accessory  thyroid  gland  at  base  of  the  tongue.     Tumor  is  nearly  spherical,  2.5  x  3  cm. 
Color,  grayish  red.     Microscopic  examination  shows  structure  like  thyroid- 

Acute  Glossitis. — Acute  glossitis,  due  to  a  spread  of  infection  from  the 
mucous  membrane,  often  secondary  to  erysipelas,  typhoid  or  systemic 
infection,  is  characterized  mainly  by  rapid  (hours)  swelling  of  the 
tongue,  accompanied  by  severe  pain  greatly  aggravated  by  motion, 
and  fever.  This  infection  may  start  from  the  lingual  tonsil,  in  which 
case  there  is  rapid  edema  of  the  glottis  with  stridor  and  dyspnea.  It 
usually  subsides  spontaneously.  It  may  progress  to  diffuse  suppura- 
tion or  circumscribed  abscess.  In  the  former  case  the  infiltration 
extends  down  the  neck  and  commonly  results  fatally  either  from  edema 
of  the  glottis  or  septic  absorption. 

Mechanical  Ulcer.^ — Mechanical  ulcer  may  be  kept  up  by  the  irritation 
of  a  misplaced  or  irregular  tooth,  causing  first  local  tumefaction,  later 
ulceration,  with  some  swelling  of  the  adjacent  tissue. 

Diagnosis  is  based  upon  the  disappearance  of  the  ulcer  or  tumor  after 
the  removal  of  the  exciting  cause,  or,  more  safely,  when  this  is  chronic 


THE  TONGUE  293 

in  type  and  has  lasted  some  time,  by  excision  of  the  ulcer  and  its 
microscopic  examination. 

Tuberculosis. — Tuberculosis  of  the  tongue  is  an  affection  of  the  adult 
already  extensively  infected.  Ulceration  is  usually  single,  at  first  round 
and  superficial,  later  undermined  or  punched-out,  and  extremely  irregular 
in  shape.  About  its  borders  are  seen  semitranslucent  tubercles.  The 
submaxillary  glands  are  enlarged.  Functional  troubles  are  pronounced 
and  the  lesions  are  usually  extremely  painful,  especially  from  contact 
with  irritating  foods. 

Diagnosis  is  based  upon  the  association  of  the  ulcer  with  other  tuber- 
culous lesions,  on  the  tuberculin  test  when  this  is  applicable,  but  most 
safely  upon  excision  and  microscopic  examination,  since  these  growths 
may  closely  resemble  cancer,  or,  if  originally  tuberculous,  may  be  the  seats 
of  malignant  degeneration.  Exceptionally  tuberculosis  of  the  tongue 
appears  in  the  form  of  small  nodules  which  soften  and  discharge  their 
cheesy  contents.  Distinction  from  gumma  is  based  upon  the  presence  of 
associated  symptoms. 

Chancre. — Chancre  of  the  tongue,  much  rarer  than  chancre  of  the  lips, 
usually  forms  a  single  flattened,  circular,  or  oval  rounded  lesion  with 
indurated  base.  It  exhibits  the  characteristic  features  of  chancre  and  is 
distinguished  from  cancer  by  its  rapid  development  and  early  adenopathy 
(days,  weeks). 

Mucous  Patches. — Mucous  patches  are  usually  placed  on  the  borders 
and  dorsal  surface  of  the  tongue.  As  a  result  of  irritation  from  carious 
teeth,  they  may  become  distinctly  ulcerated  and  inflammatory.  There 
is  at  times  a  papillary  overgrowth. 

Diagnosis  is  based  upon  associated  symptoms,  rapid  course,  extent 
and  multiplicity  of  lesions,  detection  of  the  spirochete,  and  the  results 
of  specific  treatment. 

Tertiary  Syphilis. — Tertiary  syphilis  is  expressed  in  the  forms  of 
diffuse  infiltration  or  gumma.  Diffuse  infiltration  during  the  process 
of  involution  causes  Assuring  and  deformity.  The  tongue  presents  a 
cracked  and  irregularly  lobulated  appearance  with  patches  of  epithelial 
desquamation  and  leukoplakia. 

Gummatous  tumors  which  develop  slowly  (months),  usually  on  the 
dorsum,  are  often  multiple,  occasion  but  slight  subjective  symptoms, 
and  are  prone  to  soften  and  discharge  before  reaching  the  size  of  a 
cherry.  Distinction  from  cancer  must  be  based  upon  the  syphilitic 
history,  the  test  of  treatment,  and,  in  case  of  doubt,  prompt  excision 
and  examination,  since  a  differential  diagnosis  cannot  be  made  from 
the  appearance  of  the  lesion. 

Leukoplakia. — Leukoplakia,  common  in  middle-aged  men,  partic- 
ularly those  who  smoke  and  drink  and  have  had  syphilis,  is  an 
expression  of  chronic  inflammation  of  the  mucous  membrane.  It  is 
characterized  by  the  formation  of  white  patches  made  up  of  keratinized 
epithelial  layer  placed  upon  an  area  of  submucous  sclerosis.  These 
patches  are  often  combined  with  ulcerating  cracks  and  fissures.  It 
is  an  occasional  predecessor  of  cancer  of  the  tongue. 


294  THE  HEAD,  FACE,  AND  NECK 

Cancer  of  the  Tongue. — Cancer  of  the  tongue  is  commonest  in  men 
between  the  fortieth  and  fiftieth  year  and  becomes  rare  after  seventy. 
Heredity  exercises  some  influence. 

The  favorite  seat  is  on  the  border  of  the  tongue,  particularly  that  part 
lying  close  to  the  molar  teeth.  When  placed  farther  back  and  con- 
cealed by  the  palatoglossal  fold  the  infiltration  and  ulceration  may  not 
be  detected  until  the  period  for  operation  is  past.  Pain  on  movement 
or  from  the  contact  of  acid  foods,  and  slight  bleeding,  should  suggest 
a  careful  examination  of  this  region,  both  by  palpation  and  the  use  of 
the  mirror,  since  the  rapid  extension  of  the  growth  thus  placed  makes 
early  operation  imperative. 

In  its  well-developed  form  cancer  is  unmistakable.  It  appears  as  a 
fungating  or  eroded  ulcer,  these  two  conditions  being  often  combined, 
bleeding  readily,  densely  indurated,  infiltrating  the  surrounding  tissues, 
and  accompanied  by  an  enlargement  and  hardening  of  the  lymphatics 
in  the  neck  which  are  prone  to  suppurate,  leaving  foul  cavities  in  the 
midst  of  the  infiltrated  tissue.  There  is  an  atrophic  form  comparable 
to  the  scirrhus  of  the  breast  in  which  the  progress  is  slow  and  cicatricial 
deformity  with  pronounced  atrophy  takes  place. 

Adenopathy  is  developed  more  slowly  in  the  papillary  epitheliomata 
which  have  become  implanted  on  patches  of  leukoplakia.  At  times 
the  adenopathy  is  acutely  inflammatory  in  type  and  is  due  to  infection 
carried  from  the  ulcerating  surface  and  not  to  cancerous  infiltration. 
In  all  cases  it  occurs  comparatively  early  in  the  suprahyoid  region  and 
in  the  carotid  group  of  glands. 

Pain  of  cancer  of  the  tongue  rarely  becomes  prominent  until  the 
affection  is  beyond  surgical  help.  When  infiltration  limits  the  motions 
of  the  organ  and  interferes  with  both  speaking  and  eating,  pain  may 
be  almost  intolerable.     It  often  radiates  toward  the  ear. 

The  prognosis  of  lingual  cancer  is  extremely  good,  providing  it  be 
recognized  early,  i.  e.,  when  the  diagnosis  is  made  by  excision  of  an 
ulcer  simply  on  suspicion  and  before  it  has  assumed  the  malignant  type. 
In  advanced  cases  the  prognosis  is  nearly  hopeless. 

Actinomycosis  of  the  Tongue. — Actinomycosis  may  develop  primarily 
on  the  tongue.  It  is  usually  secondary  to  infection  of  the  jaw.  It  is 
characterized  by  indurated  nodules,  at  first  covered  with  healthy  mucous 
membrane,  later  softened  and  discharging  pus  containing  actinomycotic 
granules.  Distinction  from  syphilis  and  other  infiltrations  of  the  tongue 
can  be  made  only  by  microscopic  and  cultural  examination. 

Tumor  and  cysts  of  the  tongue,  other  than  carcinoma,  angioma,  and 
ranula,  are  rare. 

Arterial  and  venous  angiomata  are  usually  associated  with  similar 
conditions  elsewhere,  and  are  occasionally  found  at  the  base  of  the 
tongue. 

Congenital  macroglossia,  often  unperceived  at  birth,  an  affection  of 
girl  babies,  due  to  lymphangioma,  may  cause  enlargement  so  great  that 
the  tongue  cannot  be  contained  in  the  mouth.  The  part  exposed  to  the 
air  presents  a  hard,  dry,  corneous  surface;  that  kept  moist  by  mucous 


THE' TONGUE 


295 


membrane  may  exhibit  papillary  outgrowth  or  an  appearance  suggest- 
ing fish-roe. 

Acquired  lymphangioma  incident  to  inflammation  and  developing 
about  adolescence  may  occasion  only  moderate  swelling.  The  fish- 
roe-like  surface  is  characteristic. 

Lingual  Goitre. — Lingual  goitre,  an  affection  confined  to  young 
women,  forms  a  rounded,  elastic,  vascular  tumor  in  the  region  of  the 
foramen  cecum.  Its  growth  is  usually  associated  with  an  abnormal 
condition  of  the  thyroid.     Its  position  is  characteristic. 

Sarcoma  of  the  Tongue. — Sarcoma  of  the  tongue  (rare)  is  characterized 
by  the  appearance  of  a  rounded,  soft,  elastic  tumor,  appearing  on  and 
part  of  the  tongue,  extremely  painful,  usually  growing  rapidly,  any 
ulcerating  before  it  reaches  a  considerable  size.  Exceptionally  the 
growth  may  be  extremely  slow.  Diagnosis  is  based  upon  the  prompt 
excision  of  a  growth  not  obviously  benign. 

Lipoma. — Lipoma  (rare)  may  be  submucous  or  intramuscular.  Be- 
cause of  its  soft  consistency  it  is  usually  mistaken  for  a  cyst.  The 
growth  is  slow  (years).  The  diagnosis,  unless  obvious,  should  be  made 
by  excision. 

Fibroma. — Fibroma  (rare),  found  on  the  dorsal  surface  of  the  tongue 
toward  its  base,  may  be  sessile  or  pediculated,  forming  rounded,  sharply 
circufnscribed,  non-inflammatory,  very  slow  growing  masses  which  may 
be  soft  or  hard.     The  diagnosis,  unless  obvious,  should  be  made  by 


excision. 


Fig.  108 


Ranula. 


Ranula. — Ranula,  a  retention  cyst,  usually  of  the  lingual  salivary  gland, 
forms  a  sausage-shaped,  translucent  tumor  beneath  the  tongue  and  on  the 
floor  of  the  mouth.  It  causes  no  symptoms  nor  functional  disturbance 
until  it  reaches  large  size.     It  is  frequently  observed  in  children. 

A  similar  cyst  due  to  obstruction  of  Wharton's  duct  is  character- 


296  THE  HEAD,  FACE,  AND  NECK 

ized  by  the  difficulty  experienced  in  probing  this  channel  and  by  the 
associated  swelling  of  the  submaxillary  gland.  The  distinction  between 
ranula  and  dermoid  when  the  latter  has  reached  large  development 
may  be  difficult. 

Dermoid  forms  a  soft,  rounded,  fluctuating  tumor,  palpable  through 
the  floor  of  the  mouth,  and  shortly  forming  an  external  swelling.  The 
symptoms  are  purely  mechanical  and  incident  to  the  size  of  growth. 
Diagnosis  is  made  by  operation. 


THE  TONSILS. 

Hypertrophy  of  the  Tonsil. — Hypertrophy  of  the  tonsil,  usually  symmet- 
rical and  associated  with  chronic  lacunar  tonsillitis,  is  obvious  on  inspec- 
tion. It  is  mainly  troublesome  because  of  recurring  acute  attacks, 
unless  the  overgrowth  be  extreme,  in  which  case  there  is  interference  with 
nasal  breathing,  and  swallowing  may  be  difficult.  Dependent  upon  it, 
even  in  the  absence  of  symptoms,  there  is  often  a  condition  of  impaired 
health,  and  in  adults  a  tendency  to  recurring  attacks  of  joint  inflamma- 
tion of  the  non-infective  type. 

Acute  Tonsillitis. — Acute  tonsillitis,  characterized  by  swelling,  pain 
aggravated  by  swallowing,  often  tenderness  on  external  pressure,  and 
lymphatic  involvement,  with  constitutional  symptoms  of  acute  infection, 
may  be  catarrhal,  lacunar,  or  parenchymatous. 

The  catarrhal  affection  is  characterized  by  moderate  symptoms,  both 
local  and  general,  and  prompt  subsidence. 

The  lacunar  tonsillitis  is  characterized  by  usually  sudden  onset  of 
fever  preceded  by  chill,  marked  systemic  depression,  and  the  appearance 
on  the  swollen  tonsils  of  dirty  white  spots  or  small  patches,  the  present- 
ing surfaces  of  lacunar  plugs.  These  spots  may  coalesce  to  a  slight 
degree,  but  exhibit  no  tendency  to  invade  the  whole  tonsillar  surface  or 
to  spread  to  the  pharyngeal  walls. 

The  distinction  from  diphtheria  should  be  made  by  microscopic  exami- 
nation of  the  cultured  exudate. 

In  its  chronic  form  this  inflammation  is  characterized  by  repeated 
and  causeless  recurrences  of  subacute  attacks,  often  impaired  general 
health  in  the  interval,  and  the  appearance  of  dilated  tonsillar  crypts, 
some  distended  and  inflamed,  others  exhibiting  yellowish,  cheesy  masses 
of  exudate.  These  may  be  concealed  by  the  half  arches  which,  in  a 
thorough  examination,  should  be  drawn  aside. 

Peritonsillar  Abscess. — Peritonsillar  abscess,  the  condition  to  which  the 
term  quinsy  is  usually  applied,  doubtless  accompanied  by  at  least  a  local 
suppuration  of  the  tonsil,  is  characterized  by  the  symptoms  which  inaugu- 
rate an  ordinary  acute  tonsillitis;  they  are  mainly  suggestive  of  abscess 
because  of  their  persistence  and  aggravation.  The  pain  steadily  increases, 
making  swallowing  impossible.  Tumefaction  is  likely  to  be  particularly 
pronounced  at  first  in  the  lateral  region  of  the  soft  palate.  The  uvula 
from  edema  resembles  a  large  polyp.     There  may  be  associated  edema 


THE  TONSILS  297 

of  the  epiglottis  and  the  aryepiglottic  folds.  The  diagnosis  is  based  upon 
the  sudden  onset  and  rapid  (days)  progression  of  symptoms.  Incision 
and  evacuation  of  pus  with  the  relief  of  symptoms  is  the  final  test. 

A  swelling  of  the  peritonsillar  tissues  and  soft  palate  may  be  caused 
by  an  erupting  wisdom  tooth. 

Chancre  of  the  tonsil  or  sarcoma  may  cause  pain  equally  as  great  and 
a  peritonsillar  swelling  closely  simulating  that  of  abscess.  In  the  former 
case  the  presence  of  an  ulcer,  in  the  latter  the  slower  onset  and  non- 
inflammatory character  of  the  growth,  is  characteristic. 

Ulceromembranous  Tonsillitis. — This  is  usually  inaugurated  by  chill 
and  fever  and  is  characterized  by  the  rapid  formation  of  sloughing 
ulceration  which  may  involve  tonsils,  half  arches,  and  the  pharynx, 
but  is  usually  confined  to  one  tonsil.  It  closely  resembles  diphtheria 
and  syphilis.  From  the  former  distinction  should  be  made  by  bacterio- 
logical examination  of  the  exudate.  The  sudden  onset,  the  rapid  course 
(days),  and  the  absence  of  specific  history  or  other  signs  of  disease  dis- 
tinguish it  from  the  secondary  manifestations  of  syphilis. 

Diphtheritic  Tonsillitis. — This  is  characterized  by  the  formation  of  a 
pseudomembrane  with  or  without  pronounced  constitutional  symptoms 
of  acute  infection  and  enlargement  of  the  cervical  glands.  The  char- 
acteristic feature  of  the  disease  is  the  comparatively  rapid  spread  of  the 
pseudomembrane  from  its  area  of  first  appearance  to  the  surrounding 
structures,  particularly  to  the  soft  palate.  At  the  edge  of  the  spreading 
exudate  there  is  a  red  inflammatory  border  of  mucous  membrane. 

Diagnosis  is  based  upon  finding  in  the  exudate  the  specific  bacillus. 

Syphilis. — Chancre. — Chancre  of  the  tonsil  is  characterized  by  the 
formation  of  an  ulcer  at  times  phagedenic  in  t}^e,  accompanied  by  pro- 
nounced enlargement  of  the  gland  and  the  peritonsillar  tissues.  The 
diagnosis  is  based  upon  the  finding  of  the  specific  organism  in  the  scrapings 
from  the  ulcer,  the  type  of  early  glandular  adenopathy,  the  rapid  exten- 
sion of  the  ulcerating  process,  often  upon  the  development  of  secondaries. 

Secondary  syphiliiic  lesions  of  the  tonsil  are  characterized  by  their 
extreme  pain  and  their  destructive  tendency.  They  can  be  distinguished 
from  phagedenic  tonsillitis  only  by  the  presence  of  more  characteristic 
associated  lesions  and  by  the  prompt  curative  effect  of  constitutional 
treatment.  Ulcerating  gummata  of  the  tertiary  period  are  usually,  but 
not  always,  painless.  They  are  deep  and  destructive  in  t}^e,  and  can  be 
distinguished  from  neoplasm  only  by  a  history  of  syphilis,  the  presence 
of  other  more  characteristic  lesions  or  their  scars,  and  the  result  of 
constitutional  treatment. 

Tuberculosis. — Tuberculosis  of  the  tonsil  exhibits  no  characteristic 
features  other  than  those  of  chronic  inflammation.  The  diagnosis  is 
suggested  by  associated  tuberculous  involvement  of  the  cervical  lym- 
phatic glands.  Lupus  of  the  pharynx  is  an  occasional  complication  of  a 
similar  condition  of  the  face  and  is  due  to  direct  extension.. 

Malignant  Disease  of  the  Tonsil. — Malignant  disease  of  the  tonsil  is  an 
affliction  of  adult  life.  Sarcoma  is  the  commonest  form.  In  its  early 
stage  it  appears  much  as  an  hypertrophied  tonsil,  the  swelling  being 


298  THE  HEAD,  FACE,  AND  NECK 

suggestive  only  because  of  its  rapid  development  without  adequate 
cause  and  without  inflammatory  symptoms.  Later,  the  large,  readily 
bleeding,  infiltrated  tumor  projecting  in  the  neck  is  characteristic. 

In  the  form  of  lymphosarcoma  the  tonsil  presents  a  pale,  nodular 
appearance. 

The  rapid  development  of  other  enlarged  lymph  glands  establishes 
the  diagnosis  of  pseudoleukemia. 

The  round-cell  and  spindle-cell  sarcomata  appear  at  first  simply  as 
hypertrophies  exhibiting  rapid  growth.  Exceptionally  the  spindle-cell 
form  may  be  encapsulated. 

Diagnosis  is  based  in  the  early  stage  of  the  affection  upon  the  causeless 
increase  in  size. 

Carcinoma,  an  affection  of  middle  and  old  age,  exhibits  an  early  ten- 
dency to  ulcerate,  involves  the  cervical  lymphatic  glands  promptly,  and 
extends  toward  the  tongue  and  palate  rather  than  toward  the  neck. 

The  diagnosis  should  be  made  by  excision. 

In  the  early  stage  of  malignant  infiltration  diagnosis  should  be  made 
by  excision  if  syphilis  can  be  excluded. 


THE  PHARYNX. 

Pharyngeal  Diverticulum. — Pharyngeal  diverticulum,  due  to  imperfect 
closure  of  the  branchial  clefts,  is  found  with  its  internal  opening  either 
in  the  tonsillar  fossa  or  the  pyriform  sinus  (between  the  aryepiglottic 
fold  and  the  wing  of  the  thyroid).  These  diverticulse  usually  occa- 
sion no  symptoms  unless  they  become  converted  into  cysts  or  fistulse. 
The  openings  of  the  latter  are  usually  found  anterior  to  the  sterno- 
mastoid  muscle  and  may  be  as  low  as  the  suprasternal  notch. 

Foreign  Bodies. — Foreign  bodies  in  the  pharynx,  if  large,  commonly 
offer  no  diagnostic  diflSculty  either  in  regard  to  their  presence  or  their 
seat.  Small  foreign  bodies  often  lodge  in  the  recesses  of  the  half  arches 
or  below  the  tonsil  in  the  sinus  pyriformis,  the  depression  to  the  side  of  the 
laryngeal  entrance.  Placed  here  they  cause  a  grating  feeling,  slight  pain 
on  swallowing,  and  edema  of  the  aryepiglottic  folds  often  of  such  extent 
as  to  occasion  dyspnea. 

Diagnosis  can  be  made  by  palpation  or  by  laryngoscopic  examination 
after  thoroughly  anesthetizing  the  mucous  membrane,  unless  the  swelling 
be  so  great  as  to  obscure  the  cause  of  it. 

Inflammation. — Chronic  superficial  inflammation  of  the  pharyngeal 
mucous  membrane  may  appear  in  the  hypertrophic  or  atrophic  form. 
The  former,  usually  spoken  of  as  granular  sore  throat,  exhibiting  char- 
acteristic glandular  and  follicular  hypertrophies,  the  latter  showing 
smooth,  glazed,  atrophic  mucous  membrane. 

Retropharyngeal  Abscess. — Acute  or  subacute  retropharyngeal  abscess, 
beginning  as  a  periadenitis  of  the  lateral  pharyngeal  lymphatic  glands, 
may  be  caused  by  infection  of  the  skin  or  of  any  part  of  the  nose  or 
mouth,  including  the  tonsil,  or  may  be  secondary  to  the  exanthemata 


THE  PALATE  299 

or  to  osteomyelitis  of  the  base  of  the  skull.  It  is  characterized  by  fever, 
dysphagia,  and  later  dyspnea.  Inspection  and  palpation  demonstrate 
the  presence  of  an  edematous  or  fluctuating  tumor.  It  is  usually 
observed  in  childhood,  and  in  the  subacute  or  chronic  form  is  distin- 
guished from  tumor  by  its  rapid  onset  and  its  age  incidence. 

The  cold  abscess  due  to  tuberculous  spondylitis  is  characterized 
by  dysphagia  and  dyspnea  and  the  formation  of  a  fluctuating,  non- 
inflammatory, postpharyngeal  tumor. 

Gumma  of  the  Pharynx. — Gumma  of  the  pharynx,  often  multiple  and 
confluent,  forms  deep,  usually  painless,  destructive  ulcers,  followed 
on  recovery  by  marked  cicatricial  deformity.  When  the  soft  palate 
is  also  involved,  and  this  is  common,  it  may  be  partly  or  wholly  de- 
stroyed, or  become  adherent  to  the  pharyngeal  wall. 


THE  PALATE. 

The  palate,  particularly  its  soft  part,  is  the  favorite  seat  of  the  early 
secondary  lesions  of  syphilis,  these  appearing  in  the  form  of  mucous 
patches  and  reaching  their  most  typical  development  when  placed  here 
and  on  the  half  arches.  Diagnosis  is  based  upon  associated  symptoms 
of  the  disease. 

Gummata,  the  usual  cause  of  perforation  of  the  palate,  are  char- 
acterized by  the  appearance  of  painless,  rounded  nodulations  which 
shortly  rupture,  discharging,  when  placed  upon  the  hard  palate,  a  frag- 
ment of  bone.  These  gummata  first  appear  upon  the  nasal  surface  of 
the  palate.  If  the  soft  palate  is  thus  involved,  a  characteristic  symptom, 
nasal  regurgitation  of  food  on  attempting  to  swallow,  should,  if  the 
history  of  syphilis  be  given,  lead  to  a  timely  diagnosis.  Gummata 
are  followed  by  extensive  destruction  and  troublesome  adhesions. 

Perforation  of  the  palate  may  be  caused  not  only  by  syphilis,  but 
by  the  erosion  of  aneurysm,  or  the  infiltration  of  a  tumor  from  the 
maxillary  sinus. 

The  tuberculous  infiltrations  and  ulcers  of  the  soft  palate  are  usually 
complications  of  pulmonary  tuberculosis.  They  form  typically  indolent, 
slowly  destructive  ulcers,  and  are  usually  so  painful  as  to  interfere  with 
deglutition. 

Polyps,  dermoids,  angiomas,  and  retention  cysts  are  observed  in  the 
region  of  the  soft  palate  and  pharynx.  They  occasion  no  symptoms 
except  from  their  size. 

Hypertrophy  of  the  uvula,  obvious  on  inspection,  is  sometimes  the 
cause  of  an  obstinate  unproductive  •  cough.  Enormous  edema  is  a 
common  accompaniment  of  the  acute  anginas,  particularly  of  peri- 
tonsillar abscess. 

The  abscess  of  dental  caries  not  infrequently  forms  a  gumboil  on 
the  hard  palate  some  little  distance  from  the  alveolar  border.  The 
diagnosis  is  readily  made  by  inspection  or  by  probing  the  resultant 
sinus. 


300  THE  BEAD,  FACE,  AND  NECK 

Mixed  tumors  develop  in  young  people  and  may  remain  almost  sta- 
tionary for  years.  The  only  symptoms  produced  are  those  incident 
to  mechanical  interference.  The  growth  is  usually  in  the  soft  palate 
and  is  slightly  nodular,  distinctly  circumscribed,  is  hard  in  some  por- 
tions and  soft  in  others,  and  is  covered  by  a  movable  mucous  membrane. 
Rapid  growth  is  significant  of  malignant  transformation.  The  diag- 
nosis should  be  made  by  removal. 

Melanosarcoma  (rare)  may  in  its  beginnings  simulate  the  discolora- 
tion of  an  angioma. 

THE  SALIVARY  GLANDS. 

Parotid  Gland.^ — ^The  parotid  gland,  roughly  triangular  in  shape, 
lies  with  its  base  extending  forward  from  the  cartilage  of  the  external 
auditory  meatus  to  a  point  on  the  cheek,  half  an  inch  to  an  inch  in  front 
of  the  condyle  of  the  lower  jaw,  and  its  apex  limited  by  a  line  drawn 
from  the  angle  of  the  jaw  to  the  tip  of  the  mastoid  process.  It  dips 
beneath  the  ramus  of  the  jaw,  the  temporomaxillary  articulation,  and  the 
mastoid  process,  and  is  enclosed  in  a  dense  layer  of  fascia,  except  at  its 
inner  portion. 

Lymph  glands  lie  in  close  contact  with  both  its  outer  and  inner  surface 
and  also  within  the  substance  of  its  lower  extension. 

The  salivary  secretion  is  carried  into  the  mouth  by  Stenson's  duct, 
about  two  and  one-half  inches  long,  which  lies  on  the  outer  surface  of 
the  masseter  muscle,  a  finger's  breadth  below  the  zygoma,  curves  around 
the  anterior  border  of  this  muscle,  and  obliquely  penetrates  the  buccinator 
muscle  and  the  mucous  membrane  of  the  mouth,  opening  opposite  the 
second  molar  tooth  of  the  upper  jaw.  Near  the  beginning  of  this  duct 
there  is  sometimes  placed  an  accessory  parotid  gland  which  may  be 
present  as  a  separate  lobe. 

In  the  substance  of  the  parotid  gland  and  traversing  it  lie  the  external 
carotid  artery  with  its  terminal  branches,  the  facial  nerve  and  its  branches, 
the  great  auricular  nerve  joining  the  facial,  and  the  auriculotemporal 
branch  of  the  inferior  maxillary  nerve. 

The  normal  parotid  gland  cannot  be  outlined  by  palpation.  Through 
its  duct  a  fine  probe  or  filiform  bougie  can  be  introduced  to  a  depth  of 
one  or  two  inches. 

When  swollen  as  a  whole,  it  forms  a  tumor  involving  the  cheek  and 
causing  a  characteristic  projection  of  the  ear;  sometimes  causing  deaf- 
ness by  closure  of  the  auditory  meatus. 

The  Submaxillary  Gland. — ^The  submaxillary  gland  lies  in  a 
pocket  of  the  deep  cervical  fascia  to  the  inner  side  of  the  body  of  the 
jaw  just  anterior  to  its  angle.  Its  upper  posterior  border  is  grooved 
by  the  facial  artery.  It  discharges  its  secretion  through  Wharton's  duct, 
about  two  inches  in  length,  opening  through  a  small  slit  in  the  side  of 
the  frenum  near  its  lingual  attachment.  Into  this  opening  a  fine  probe 
can  be  introduced.  Because  of  its  position  beneath  the  muscular  floor 
of  the  mouth  swellings  of  glands  are  apt  to  appear  externally.     The 


THE  SALIVARY  GLANDS  301 

submaxillary  gland  is  best  palpated  between  the  index  finger  of  one  hand 
passed  to  the  floor  of  the  mouth  and  the  index  and  middle  finger  of  the 
other  hand  pressing  upward  beneath  the  jaw. 

The  Sublingual  Gland. — The  sublingual  gland,  placed  just  beneath 
the  mucous  membrane  of  the  floor  of  the  mouth,  forms  at  the  side  of  the 
frenum  a  ridge-like  projection  which  can  be  seen  and  felt.  It  frequently 
sends  extensions  into  the  mylohyoid  muscle.  It  discharges  its  secretion 
through  numerous  ducts  opening  at  the  side  of  the  frenum  behind  the 
termination  of  Wliarton's  duct  through  an  overlying  mucous  mem- 
brane projection  called  the  plica  sublingualis.  Swellings  of  the  sub- 
lingual gland  project  prominently  into  the  mouth. 

General  Symptomatology. — ^The  chief  characteristic  of  surgical  affections 
of  the  salivary  glands  is  swelling.  This  may  be  inflammatory  or  non- 
inflammatory in  type,  may  be  rapid  or  slow  in  onset,  may  be  general, 
involving  the  whole  gland,  or  may  be  local,  appearing  as  a  tumor. 

General  enlargement  of  the  parotid  gland,  if  acute  in  onset,  is  usually 
due  to  mumps  or  to  obstruction  of  Stenson's  duct  (calculus  or  foreign 
body)  or  to  acute  infection. 

A  general  enlargement  of  gradual  onset  is  incident  to  chronic  inflam- 
mation which  may  be  secondary  to  duct  obstruction.  It  may  be  an 
expression  of  syphilitic  or  malignant  infiltration  or  may  be  a  feature  of 
Mikulicz's  disease. 

A  localized  tumor  of  the  parotid  gland,  if  this  be  acutely  inflammatory 
in  type,  may  be  due  to  an  abscess  of  a  portion  of  the  parotid  gland;  more 
commonly  it  is  incident  to  suppuration  of  the  lymphatic  glands  in  its 
substance  or  upon  its  surface.  Tumors  formed  in  the  absence  of  inflam- 
matory symptoms  are  usually  due  to  inflammatory  hyperplasia  of  the  lymph 
glands  lying  within  and  upon  the  parotid.  Mixed  tumors  are  the  next 
common  source  of  such  localized  swellings,  while  cysts,  carcinoma, 
gumma,  tuberculosis,  and  actinomycosis  are  rare. 

Mumps. — Characterized  by  the  rapid  (hours)  development  of  a  non- 
indurated,  extensive,  usually  bilateral  parotid  swelling  which  quickly 
reaches  its  maximum  (one  or  two  days)  and  subsides  without  the  local 
or  general  symptoms  of  pus  formation.  The  submaxillary  gland  may  be 
attacked  alone  or  with  the  parotid.  It  may  be  complicated  by  orchitis, 
pancreatitis,  ovaritis,  or  mastitis. 

A  non-suppurative  parotiditis  less  sudden  in  onset  and  more  persistent 
in  course  may  be  caused  by  mercury  or  the  iodides,  may  follow  trauma, 
or  may  develop  as  an  expression  of  gout  or  other  toxemic  condition. 

The  diagnosis  is  suggested  by  the  sudden,  apparently  causeless  onset, 
the  exclusion  of  the  usual  causes  of  swelling  in  this  region,  i.  e.,  dental 
caries  and  an  erupting  wisdom  tooth,  often  by  the  prompt  subsidence  of 
the  inflammation. 

Acute  General  Swelling  of  the  Parotid  Secondary  to  Sudden  Obstruction 
of  Stenson's  Duct. — This  may  be  the  result  of  salivary  calculus,  foreign 
body,  or  an  acute  exacerbation  of  a  chronic  inflammation. 

Calculus,  aside  from  mumps,  is  the  commonest  form  for  an  acute 
swelling  of  the  parotid  attacking  a  person  in  previous  health.     The  pain 


302  THE  HEAD,  FACE,  AND  NECK 

and  tumefaction  come  on  while  eating,  or  are  greatly  aggravated  by  this, 
and  usually  subside  with  a  free  flow  of  saliva,  to  recur  again  and  again. 
The  calculus,  commonest  in  yoiing  and  middle-aged  men,  may  be  lodged 
into  the  duct  or  one  of  its  subdivisions.  It  can  be  palpated  by  passing  the 
thumb  into  the  mouth  and  the  index  finger  of  the  same  hand  on  the  cheek 
along  the  course  of  Stenson's  duct  (a  finger's  breadth  below  the  zygoma). 
It  is  usually  shaped  like  a  thin  olive  stone. 

Foreign  body  is  characterized  by  the  same  suddenness  of  onset;  both  it 
and  calculus  are  more  common  in  the  submaxillary  than  in  the  parotid 
duct.  Foreign  body  is  a  cause  of  stone  and  of  chronic  inflammation  of 
the  duct,  causing  thickness,  ultimate  dilatation,  and  purulent  discharge 
which  can  be  squeezed  out.  This  chronic  duct  inflammation  is  char- 
acterized by  intermittent  attacks  of  salivary  colic.  It  is  sometimes 
associated  with  emphysematous  crackling  on  pressure  over  the  gland 
(glassblowers). 

In  all  forms  of  obstruction  the  orifice  of  the  duct  is  swollen  and  in- 
flamed and  pain  and  swelling  are  markedly  increased  while  eating. 

The  cause  of  the  obstruction,  whether  it  be  calculus,  foreign  body, 
stricture,  or  chronic  inflammation,  can  be  determined  by  cocainizing  the 
orifice  of  the  duct,  milking  it  of  its  contents,  which  should  be  carefully 
examined,  and  introducing  into  it  fine  probes  and  bougies. 

Parotiditis  secondary  to  operation  or  systemic  infection  develops,  as  does 
possibly  mumps,  in  a  gland  predisposed  to  infection,  by  extension  of 
infection  from  the  mucous  membrane  of  the  mouth.  It  follows,  usually 
within  a  week,  abdominal  operations,  particularly  those  upon  the  genital 
tract  of  women,  and  is  an  occasional  complication  of  puerperal  fever, 
typhoid,  pneumonia,  indeed,  any  of  the  infectious  diseases. 

It  begins  with  pain,  swelling,  and  tenderness  of  the  parotid  gland, 
usually  of  one  side,  attended  with  symptoms  of  sepsis.  The  jaw  may  be 
fixed.  In  patients  of  dulled  sensibilities  because  of  intercurrent  disease 
swelling  may  be  the  only  symptom.  The  inflammation  may  gradually 
subside  as  one,  usually  many,  abscess  forms.  There  may  be  slough- 
ing of  the  entire  gland.  Pus,  if  not  evacuated,  may  burst  into  the  ear, 
may  form  a  postpharyngeal  abscess,  involve  the  temporomaxillary 
joint,  or  burrow  to  the  mediastinum.  If  recovery  takes  place,  facial 
palsy  and  salivary  fistulse  may  follow. 

If  only  the  lower  part  of  the  parotid  be  involved  in  acute  suppurative 
inflammation,  this  condition  cannot  be  distinguished  from  a  similar  one 
attacking  the  lymphatic  glands  placed  in  the  parotid  or  deeply  along  its 
under  surface.  A  lesion  of  the  nasopharynx.  Eustachian  tube,  or  middle 
ear  might  suggest  the  probability  of  a  secondary  adenitis. 

Syphilitic  parotiditis,  developing  in  the  secondary  stage  of  the  disease 
and  characterized  by  swelling,  pain,  tenderness,  and  salivation,  has  been 
described  by  Newmann. 

Chronic  parotiditis  may  come  on  with  acute  symptoms  of  moderate 
severity,  the  primary  swelling  persisting  for  weeks  and  months  and  grad- 
ually subsiding  uninfluenced  by  treatment.  The  constitutional  symp- 
toms of  suppuration  are  wanting.     The  condition  is  diagnosticated  by 


THE  SALIVARY  GLANDS 


303 


the  absence  of  demonstrable  cause  and  its  persistence.  It  cannot  be 
distinguished  from  an  infiUrating  mahgnant  growth  except  by  its  more 
rapid  onset  (liours  or  days),  the  prompt  involvement  of  the  whole  gland, 
and  the  circumstance  that  it  is  not  progressive  after  the  first  week. 

Symmetrical  Enlargement  of  the  Lacrymal  and  Salivary  Glands  (Mikulicz's 
Disease). — Mostly  observed  in  the  third  decade,  it  is  characterized  by  a 
slow  (months  or  years)  enlargement  of  the  salivary  and  of  the  lacrymal 
glands.  All  three  of  the  larger  salivary  glands,  together  with  the  palatine, 
the  buccal,  the  labial,  and  the  Blandin  Nuhn  gland  on  the  under  surface 
of  the  tip  of  the  tongue  may  be  synchronously  involved. 

Malignant  infiltration  exceptionally  causes  fairly  rapid  (weeks),  almost 
symmetrical  enlargement  of  the  parotid  gland  which  cannot  be  distin- 
guished from  that  incident  to  inflammatory  hyperplasia,  and  may  be  an 
immediate  sequel  of  the  latter.  The  diagnosis  to  be  of  service  can  be 
made  onlv  bv  excision. 


Fig. 

109 

i 

i 

% 

1 

F^ 

"'^B' 

4 

■'^-' 

3 

- 

! 

1 

■ti 

t 

li 

,\ 

i 

\ 

Mixed-cell  sarcoma  of  IjTiiph.  glands.  Duration,  six  months;  non-inflammatory;  no  pain;  no 
tenderness;  skin  non-adherent;  numerous  glands  enlarged,  soft  and  adherent  to  one  another;  mouth, 
nose,  throat,  ear,  eye,  and  scalp  normal.      (Heam.) 

Lymph  Glands. — Lymph  glands,  if  enlarged  from  either  inflammatory 
h\-perplasia  or  tuberculous  infiltration,  when  placed  in  the  parotid  or 
beneath  its  deep  surface,  cannot  be  distinguished  from  a  beginning  parotid 
tumor.  jNIalignant  Ijonphoma,  lymphosarcoma,  and  leukemic  lymphoma 
may  each  begin  in  the  parotid  lymphatics. 


304 


THE  HEAD,  FACE,  AND  NECK 


Salivary  Cysts. — ^These  may  form  at  the  expense  of  the  duct  or  of  the 
gland  substance,  and  are  due  to  narrowing  or  obUteration  of  the  passages. 

The  duct  cyst  forms  a  fluctuating,  fusiform  swelHng  in  the  course  of 
Stenson's  duct,  often  associated  with  enlargement  of  the  gland. 

The  gland  cysts  grow  very  slowly  (years),  and  are  not  recognized  as 
such  until  they  reach  moderate  size.  They  form  single,  soft,  fluctuating 
tumors,  incision  into  which  is  followed  by  fistula. 

Congenital  Cysts. — Lymphangioma  forms  an  ill-defined,  lobulated, 
fluctuating  tumor  (see  Lymphangioma  of  the  Neck),  the  seat  of  which 
in  the  salivary  glands  can  be  detected  only  by  excision  and  examination. 
The  same  may  be  said  of  angioma. 


Fig.  110 


Mixed   sarcoma   of   the   parotid,  showing   typical   displacement   of   the   external   ear. 
months.     Lobulated  and  varying  greatly  in  density  in  the  various  parts. 


Duration, 


Lipoma  may  be  infiltrating  or  simply  adjacent,  lying  in  the  parotid 
space  and  displacing  the  gland.  In  either  case  the  growth  is  slow  (years). 
There  is  pseudofluctuation  and  the  tumor  seems  superficial.  It  has  been 
confounded  with  cyst. 

Fibroma  and  chondroma  exhibit  the  symptoms  of  mixed  tumors. 

Mixed  Tumors. — These  may  be  benign  or  malignant.  They  begin  at 
any  period  of  life  as  painless,  rounded,  movable  nodules,  often  discovered 
accidentally  because  of  a  favoring  arrangement  of  lights  and  shadows. 
They  may  remain  indolent  for  months  or  years.     This  latent  period 


THE  SALIVARY  GLANDS  305 

may  be  followed  by  one  in  which  the  tumor  rapidly  increases  in  size, 
usually  toward  the  surface,  exceptionally  toward  the  pharynx,  forming 
a  bosselated  mass,  soft  in  one  place,  of  bony  hardness  in  another,  which 
does  not  infiltrate  the  surrounding  parts,  and  remains  freely  movable 
even  when  the  orowth  has  reached  large  size. 

Pressure  symptoms  are  late  in  developing.  Increased  salivation  is 
sometimes  so  pronounced  as  to  be  most  distressing.  The  cervical 
lymphatic  glands  are  not  involved.     These  tumors  may  reach  huge  size. 

The  diagnosis  should  be  made  by  excision. 

Sarcoma  of  the  parotid  should  be  diagnosticated  by  excision  and  micro- 
scopic examination.  In  its  origin  and  clinical  course  it  closely  resembles 
mixed  tumor,  except  the  round-cell  form,  which  by  a  rapid  infiltration 
of  the  whole  gland  may  simulate  a  subacute  parotiditis.  This  form 
quickly"  invades  the  surrounding  tissues. 

Carcinoma,  either  secondary  by  direct  extension  from  neighboring 
parts  or  primary  in  the  salivary  glands,  is  predisposed  to  by  previous 
inflammation.     It  occurs  in  the  encephaloid  and  scirrhous  forms. 

It  begins  as  a  hard,  at  first  painless,  tumor.  The  encephaloid  form, 
which  may  develop  at  any  time  of  life,  grows  rapidly,  forming  a  large, 
soft,  lobulated  tumor  which  shortly  breaks  through  the  skin,  resulting 
in  foul,  fungating,  bleeding  ulcers  attended  with  extensive  ganglionic 
enlargement. 

The  scirrhous  form,  an  affection  of  old  men,  densely  infiltrates  the 
entire  parotid  region,  retracting  the  skin  and  so  involving  the  muscles 
that  fixed  jaw  and  wry-neck  may  be  produced.  In  both  forms  of  carci- 
noma facial  palsy,  extreme  pain,  venous  engorgement,  and  difficulty  in 
mastication  and  deglutition  develop. 

Diagnosis  should  be  made  in  the  early  stage  of  growth  by  excision 
and  microscopic  examination. 

Gumma. — Gumma  (rare)  forms  in  the  parotid  gland  a  painless,  indu- 
rated, slowly  growing  (months)  tumor,  infiltrating  the  skin  and  surround- 
ing parts,  and  either  softening  and  ulcerating  or  undergoing  absorption. 
In  its  early  development  it  exactly  simulates  malignant  infiltration,  nor 
can  it  be  distinguished  from  the  latter  except  by  the  therapeutic  test  of 
mercury,  time  for  which  should  not  be  taken  unless  there  is  a  perfectlv 
clear  history  of  syphilitic  infection. 

Tuberculosis. — Tuberculosis  (rare),  usually  of  the  lymphatic  glands 
lying  in  or  on  the  parotid,  forms  an  ill-defined  tumor  which  in  the 
course  of  months  softens  and  discharges  through  one  or  several  sinuses. 
It  cannot  be  distinguished  from  other  timior  formations  in  the  early  stages, 
since  it  may  develop  in  persons  free  from  other  signs  of  tuberculosis. 

Actinomycosis. — Actinomycosis  is  usually  secondary,  characterized  bv 
the  typical,  dense  infiltration,  multiple  sinus  formation,  and  the  finding 
of  the  characteristic  granules  in  the  discharge  or  in  the  infiltrate  removed 
by  operation. 

Salivary  Fistula. — Salivary  fistula  may  form  in  consequence  of  trauma- 
tism or  necrotic  inflammation  of  either  the  gland  or  its  duct  and  usually 
closes  spontaneously.  The  diagnosis  is  readily  made  by  the  flow  of 
20 


306  THE  HEAD,  FACE,  AND  NECK 

saliva  through  an  abnormal  opening,  increased  in  quantity  by  the  act 
of  eating. 

The  Submaxillary  Gland. — ^The  submaxillary  gland  is  subject  to  the 
affections  observed  in  the  parotid  gland,  including  mumps.  It  is  in  its 
duct  particularly  that  foreign  bodies  and  salivary  calculi  are  found. 

The  entrance  of  a  foreign  body  (fish-bone,  fruit-seeds,  etc.)  is  charac- 
terized by  sudden  pain  and  swelling  of  the  gland,  felt  by  external  or 
bimanual  palpation. 

Salivary  stone  is  evidenced  by  a  lump  in  the  floor  of  the  mouth  and 
by  intermittent  attacks  of  pain  and  swelling  coming  on  during  meals. 
Whether  the  obstruction  be  due  to  stone  or  foreign  body,  there  is  a 
catarrhal  condition  of  the  duct  with  a  red,  swollen  papilla.  Inspection, 
palpation,  and  probing  will  formulate  the  diagnosis. 

Mixed  tumors  of  the  gland  project  primarily  toward  the  skin  surface 
internal  to  the  body  of  the  jaw  just  in  front  of  its  angle. 

The  sublingual  glands  are  particularly  subject  to  cystic  dilatation, 
forming  the  affection  called  ranula,  characterized  by  a  painless,  slowly 
growing,  semitranslucent,  fluctuating  tumor  in  the  floor  of  the  mouth, 
commonest  in  women  (see  p.  295). 


THE  NECK. 

Congenital. — Malformations  and  Distortions. — (1)  Branchial  fistulse 
or  cysts;  (2)  skin  tabs;  (3)  teratoma;  (4)  cervical  rib;  (5)  congenital  wry- 
neck. 

Branchial  Fistulse. — Branchial  fistulse  or  cysts  are  due,  when  placed 
laterally,  to  imperfect  closure  of  the  second  branchial  cleft;  when  placed 
centrally,  to  a  persistent  thyroglossal  duct.  They  may  be  complete,  open- 
ing upon  both  the  skin  and  the  mucous  surface,  or  incomplete,  opening 
upon  one  surface,  or  without  either  opening  forming  a  cyst.  Though 
present  at  birth,  they  may  not  produce  symptoms  until  long  after. 

The  lateral  fistula,  usually  on  the  right  side,  forms  an  indurated  cord 
which  passes  upward  beneath  the  sternomastoid  and  discharges  intermit- 
tently a  turbid,  mucous  secretion,  which  keeps  the  surrounding  skin  in  an 
eczematous  condition.  The  surface  opening  is  placed  along  the  inner 
border  of  the  sternomastoid  muscle;  the  internal  opening  is  in  the  lateral 
wall  of  the  pharynx  near  the  base  of  the  tonsil,  the  tract  passing  between 
the  internal  and  external  carotid  beneath  the  digastric  muscle  and  being 
adherent  to  the  sheath  of  the  vessels. 

The  injection  of  an  ill-tasting  fluid  from  the  external  orifice  will 
establish  the  diagnosis. 

Median  fistula  very  rarely  manifests  its  presence  at  birth.  Palpation 
shows  an  indurated  cord  in  the  midline  with  the  external  opening 
between  the  hyoid  bone  and  the  suprasternal  notch. 

Skin  Tabs. — Skin  tabs,  containing  cartilage,  at  times  bilateral,  sym- 
metrical, and  resembling  supernumerary  ears,  are  found  along  the 
anterior  border  of  the  sternomastoid  muscle. 


THE  NECK 


307 


Teratoma. — Teratoma  (rare)  forms  a  congenital  tumor  in  the  antero- 
lateral region  of  the  neck  which  cannot  be  distinguished  from  goitre, 
since  it  moves  with  the  larynx. 

Congenital  Wry-neck. — ^The  expression  of  a  traumatic  or  toxic  myositis 
resulting  in  fibroid  degeneration  and  contracture  of  the  sternomastoid 
muscle  is  characterized  by  drawing  of  the  head  toward  the  affected  side, 
while  the  face,  if  the  sternomastoid  be  the  only  muscle  contractured,  is 
turned  toward  the  healthy  side.     Any  of  the  muscles  of  the  neck  may  be 


Fig.  Ill 


Congenital  torticollis.     Right  sternomastoid  muscle.     Typical  position. 

involved.  Motion  is  limited  and  the  contracted  muscle  becomes  promi- 
nent when  an  effort  is  made  to  correct  the  position  of  the  head.  As  a 
result  of  the  fixed  faulty  position  there  is  facial  asymmetry  and  later 
curvature  of  the  spine. 

Cervical  Rib. — Cervical  rib,  a  malformation  growing  from  the  seventh 
cervical  vertebra,  and  with  its  end  free  or  attached  to  the  first  dorsal 
rib,  usually  causes  no  symptoms.  Exceptionally  after  puberty  in  its 
growth  it  presses  on  the  brachial  plexus,  causing  pain  and  weakness  of 
the  arm  and  a  prominence  of  the  subclavian  artery  which,  on  examina- 
tion, is  found  to  depend  upon  an  underlying  bony  swelling  distinguishable 
from  outgrowth  of  the  first  rib  or  the  vertebral  processes  by  the  x-rays. 

Traumatisms. — Contusions. — Contusions  or  sprain  of  the  sterno- 
mastoid muscle  causes  a  blood  effusion  into  its  sheath,  noted  in  the 


308  THE  HEAD,  FACE,  AND  NECK 

newly  born  after  difficult  labor.  Trauma  of  the  vertebral  column  may 
cause  contusion  or  sprain  with  or  without  injury  to  its  contents,  or  luxa- 
tion or  fracture  with  or  without  injury  to  the  cord  (see  p.  336). 

Contusions  of  the  Brachial  Plexus. — This  may  follow  direct  trauma, 
occupation,  as  from  carrying  heavy  weights  on  the  shoulder,  or  posi- 
tion (anesthesia  palsy),  the  nerves  in  the  latter  case  being  compressed 
by  the  clavicle  thrown  upward  and  backward,  as  in  the  Trendelenburg 
position  with  arms  suspended.  It  is  characterized  by  anesthesia  and 
by  palsy  of  motion.  This  form  of  palsy  is  observed  in  the  newly 
born  even  when  the  clavicle  has  not  been  broken. 

Contusion  of  the  larynx,  such  as  that  produced  by  a  sudden  blow 
with  the  outer  border  of  the  hand,  may,  even  in  the  absence  of  gross 
lesions,  cause  sudden  death  by  cardiac  inhibition.  There  are  usually 
distinct  lesions  characterized  by  blood  effusion  beneath  the  mucous 
membrane,  by  edema,  and  more  or  less  fixation  of  the  cords.  The 
immediate  effect  is  dyspnea  and  intense  pain,  aggravated  by  all  move- 
ments of  the  larynx  (p.  322). 

A  cricothyroid  luxation  is  characterized  by  intense  pain  and  dyspnea, 
and  deformity,  usually  masked  by  swelling. 

Fracture  of  the  Larynx.- — ^Fracture  of  the  larynx  may  occur  in  children 
and  in  adults.  It  usually  involves  the  thyroid  cartilage,  next  in  order 
the  cricoid,  not  infrequently  both  (see  p.  322). 

Emphysema  favored  by  coughing  may  come  on  immediately,  and  by 
rapid  extension  to  the  mediastinum  may  destroy  life. 

As  a  result  of  trauma  or  forced  expiratory  efforts,  as  in  coughing,  a 
pneumocele  may  develop.  It  forms  a  resonant,  sometimes  crepitant, 
tumor,  the  tension  of  which  is  increased  by  expiratory  effort.  It  is 
placed  near  the  course  of  the  trachea  or,  when  it  is  due  to  hernia  of  the 
lung,  in  the  supraclavicular  fossa. 

Fracture  of  the  Hyoid  Bone. — Fracture  of  the  hyoid  bone,  commonly 
due  to  pinching  force,  is  characterized  by  great  pain,  local  tenderness, 
difficulty  in  talking  or  swallowing,  and  often  cough  and  dyspnea, 
sometimes  bloody  expectoration  from  injury  of  the  pharyngeal  mucous 
membrane.  Either  the  cornua  or  the  body  may  be  broken.  Unnatural 
mobility,  and  even  crepitus,  can  be  detected  either  by  external  palpa- 
tion or  by  examining  with  a  finger  of  one  hand  introduced  into  the 
mouth  while  those  of  the  other  make  external  pressure.  The  ic-rays 
will  usually  show  the  nature  of  the  injury. 

Vascular  Wounds. — ^Wounds  of  veins  are  characterized  by  free  bleeding 
and  sometimes  the  entrance  of  air  by  aspiration,  particularly  if  the 
vein  walls  are  adherent  to  a  surrounding  infiltration.  Ligation  of 
one  or  both  jugular  veins  is  not  entirely  devoid  of  danger  incident  to 
back  pressure.  Ligation  of  either  one  or  both  common  carotid 
arteries  is  likely  to  be  followed  by  acute  cerebral  softening,  apoplexy, 
and  death. 

Injury  of  the  thoracic  duct,  suggested  by  a  continuous  flow  of  chyle 
from  the  wound,  is  rarely  of  grave  moment,  the  flow  ceasing  spontane- 
ously because  of  cicatrization  and  accessory  openings. 


THE  NECK  309 

Injury  to  the  vagus,  if  unilateral,  is  followed  by  laryngeal  hoarseness 
and  palsy  of  the  vocal  cord,  often  by  pulmonary  edema. 

Injury  to  the  cervical  sympathetic  causes  contracted  pupil  and  con- 
gestion and  increased  temperature  on  the  side  of  the  face. 

Injury  of  the  spinal  accessory  results  in  paralysis  of  the  sternomastoid 
and  trapezius  muscles. 

Affections  Characterized  by  Fixed  Positions  of  the  Head. — Acquired 
Wry-neck. — Torticollis  may  suddenly  develop  as  a  result  of  traumatism. 
It  is  then  due  to  luxation  characterized  by  bony  deformity,  to  myositis 
incident  to  blood  clot  in  the  substance  of  the  muscle  itself,  evidenced 
by  localized  swelling  and  tenderness,  or  to  deeper  blood  effusion  caus- 
ing irritation  of  the  nerve  roots. 

It  may  be  rapid  in  development  and  non-traumatic,  coming  on  often 
in  the  night  and  due  to  a  myositis,  usually  termed  rheumatic,  but 
possibly  secondary  to  any  infection.  This  form  of  torticollis  is  common 
in  children  with  slight  sore  throats  and  is  characterized  by  a  fixed 
position  of  the  head,  usually  in  lateral  flexion  with  slight  rotation.  The 
muscle  affected  is  tender  and  rigid  to  palpation  and  there  is  pain  on 
motion.  The  condition  is  usually  transitory,  but  may  become  chronic, 
resulting  in  permanent  contracture. 

A  similar  form  of  torticollis  develops  as  an  expression  of  rheumatism 
of  the  vertebral  articulations,  and  is  marked  by  tenderness  over  the 
spine. 

Torticollis  due  to  gummatous  infiltration  of  the  sternomastoid  muscle, 
either  circumscribed  or  diffuse,  is  characterized  by  the  painless  pro- 
gression of  such  an  infiltrate  in  a  person  giving  a  syphilitic  history. 

Torticollis  secondary  to  caries  of  the  vertebrae  is  evidenced  by  more 
gradual  onset,  fixed  position,  tenderness  over  the  involved  vertebra,  also 
elicited  by  jarring  the  head  downward,  and  tonic  contraction  of  the 
involved  muscles. 

Torticollis  secondary  to  deep  cervical  adenitis  exhibits  the  additional 
symptoms  of  glandular  inflammation. 

The  torticollis  symptomatic  of  a  basilar  meningitis,  mastoiditis,  and 
parotitis,  or  a  cerebral  hemorrhage  involving  the  motor  centres,  exhibits, 
in  addition  to  wry-neck,  the  symptoms  of  a  major  condition. 

Spasmodic  torticollis  characterized  by  tonic  and  clonic  contractions 
of  the  muscles  supplied  by  the  spinal  accessory  nerve,  occurs  in  neu- 
rotic individuals,  often  without  definite  cause.  In  the  variety  char- 
acterized by  tonic  spasm,  the  diagnosis  can  be  formulated  by  excluding 
the  usual  recognized  causes  of  the  contracture,  the  absence  of  tender- 
ness or  other  symptoms  of  myositis,  and  often  by  the  development  of 
an  hypertrophy  of  the  muscles  involved. 

Acute  Inflammatory  Affections  of  the  Neck. — These  are  mani- 
fested by  the  rapid  development  (days)  of  well-marked  local  and 
constitutional  symptoms  of  inflammation.  If  the  skin  infections  be 
excepted,  they  usually  begin  in  lymphatic  glands,  and  secondarily 
involve  the  surrounding  tissues.  Acute  osteomyelitis,  particularly  of 
the  lower  jaw  and  mastoid  process,  exceptionally  of  the  vertebra  or 


310  THE  HEAD,  FACE,  AND  NECK 

base  of  the  skull,  is  an  occasional  underlying  cause.  ■  Exceptionally  the 
infection  may  occur  through  puncture  or  erosion  of  the  esophagus  or 
the  air  passages. 

The  acute  superficial  infections  are  represented  by  furuncle  and 
carbuncle  commonly  placed  at  the  back  of  the  neck  at  the  collar  line 
and  beginning  as  a  follicular  infection.  Anthrax  occasionally  develops. 
All  of  these  infections  run  a  characteristic  course. 

Acute  Adenitis. — Acute  adenitis,  commonest  in  children  before  the 
tenth  year,  and  secondary  to  a  focus  of  infection  in  the  area  from  which 
the  lymphatics  drain  into  the  affected  glands,  usually  develops  beneath 
the  lower  jaw,  just  behind  its  angle,  or  in  one  or  more  of  the  group  of 
glands  lying  high  in  the  neck  close  to  the  great  bloodvessels. 

Submental  adenitis  (acute),  sometimes  called  sublingual  abscess, 
limited  in  its  extension  by  the  sides  of  the  jaw,  forms  a  tender  tumor 
beneath  the  skin  just  behind  the  symphysis.  The  glands  involved 
are  the  submental  group  placed  between  the  anterior  bellies  of  the 
digastric  on  the  surface  of  the  myelohyoid  muscles.  Into  them  are 
drained  the  lymphatics  of  the  midportion  of  the  lower  lip,  chin,  gums, 
and  floor  of  the  mouth,  and  the  tip  of  the  tongue.  They  communi- 
cate with  the  submaxillary  group  of  glands. 

Submaxillary  adenitis  (acute)  forms  a  tender  tumor  beneath  the 
chin  limited  in  its  extension  by  the  body  of  the  jaw  and  the  hyoid  bone. 
The  submaxillary  glands  are  placed  along  the  inner  border  of  the  body 
of  the  lower  jaw,  with  often  one  or  two  glands  on  its  outer  surface. 
Lymph  to  these  submaxillary  glands  flows  from  the  face,  the  lips,  the 
gums,  the  anterolateral  border  of  the  tongue. 

Since  the  swelling  of  submaxillary  adenitis  is  likely  to  extend  from 
beneath  the  jaw  slightly  on  to  the  cheek  surface,  it  may  readily  be  con- 
founded with  an  osteoperiostitis  of  the  lower  jaw.  In  the  latter  case, 
the  greatest  swelling  is  to  the  outer,  rather  than  to  the  inner,  side  of 
the  base  of  the  jaw  and  the  tumor  will  be  found  firmly  adherent  to  the 
bone.     The  two  conditions  are,  however,  often  associated. 

Exceptionally,  virulent  and  rapidly  infiltrating  infection  from  a  carious 
tooth  or  inflamed  tonsil  may  invade  the  deep  cellular  tissues  of  the 
neck.  This  is  characterized  by  brawny  submaxillary  infiltration, 
followed  shortly  by  chill,  fever,  and  symptoms  of  profound  toxemia, 
dysphagia,  dyspnea,  and  fixation  of  the  jaws  and  head.  The  floor 
of  the  mouth  is  elevated  and  edema  of  the  glottis  is  likely  to  occur. 

This  affection  is  distinguished  from  an  ordinary  submaxillary  sup- 
purative adenitis  by  the  violence  of  the  local  and  constitutional  symp- 
toms. 

A  tender  swelling,  near  or  behind  the  angle  of  the  jaw,  accompanied 
by  a  severe  pain,  often  radiating  to  the  ear,  and  inability  to  open  the 
mouth,  occurring  after  puberty,  and  without  obvious  surface  lesion, 
is  usually  due  to  an  erupting  wisdom  tooth.  The  diagnosis  is  best 
formulated  by  the  a:;-rays. 

Superficial  Cervical  Adenitis. — Superficial  cervical  adenitis  is  second- 
ary to  infection  of  the  area  draining  primarily  into  the  subauricular 


THE  NECK 


311 


or  suboccipital  glands,  or  of  the  external  ear  and  back  of  the  neck, 
draining  directly  into  the  cervical  glands  placed  along  the  posterior 
border  of  the  sternomastoid  and  superficial  to  it.  Between  these  glands 
and  the  deep  set  there  is  a  free  communication. 

Deep  Cervical  Adenitis. — Deep  cervical  adenitis  involves  the  chain  of 
glands  which  pass  along  the  course  of  the  internal  jugular  vein.  The 
upper  group  of  the  deep  set  is  made  up  of  many  small  glands  behind 
the  sternomastoid,  and  a  few  large  glands  in  close  relation  to  the  internal 
jugular  vein. 


Fig.  112 


Chronic  cervical  adenitis.  Fifteen  years'  duration;  submaxillary  group  and  anterior  cervical 
chain  of  lymph  glands  enlarged,  hard,  non-sensitive,  and  slightly  adherent,  with  normal  overlying 
skin.     (Carnett). 

Into  them  is  drained  the  lymph  from  all  the  glands  placed  super- 
ficially and  above,  and  also  that  from  the  gums,  tongue,  tonsils,  nasal 
cavity,  pharynx,  thyroid  gland,  larynx,  and  esophagus.  The  lower 
deep  cervical  set  of  glands  receives  all  the  lymph  from  above  and  that 
from  the  back  of  the  neck  and  scalp,  the  breast  and  the  axilla. 

There  develops  a  swelling  beneath  the  sternomastoid  or  behind  it 
which  shortly  infiltrates  this  muscle,  fixing  the  head  in  a  position  of 
wry-neck.     Since  the  inflammation  is  beneath  the  deep  fascia,  both 


312     -  THE  HEAD,  FACE,  AND  NECK 

dyspnea  and  dysphagia  may  be  observed,  together  with  marked  con- 
stitutional symptoms.  The  pus  may  burrow  into  the  mediastinum, 
may  erode  a  large  bloodvessel,  or  may  discharge  through  the  esophagus 
or  the  air  passages.  Suppuration  of  the  lower  deep  group  may  burrow 
into  the  axilla. 

The  deep  cervical  glands  are  subject  to  suppurative  adenitis  second- 
ary to  infections  of  the  throat,  particularly  that  incident  to  the  erup- 
tive fevers. 

Acute  thyroiditis  (p.  327)  and  osteomyelitis  of  the  cervical  vertebrae 
(see  p.  340)  are  elsewhere  described. 

Affections  Characterized  by  Tumor  Formation  with  Inflammatory 
Symptoms  Slight  or  Wanting. — Inflammatory  Hyperplasia. — Second- 
ary to  peripheral  infection,  or  engendered  by  the  irritation  incident 
to  blood  absorption,  as  from  simple  contusion,  or  following  la  grippe 
or  other  form  of  toxemia,  there  may  be  found  one  or  more  small  ovoid, 
tender  nodules  in  the  position  occupied  by  the  lymphatic  chains. 
Usually,  the  hyperplastic  glands  develop  insidiously  as  the  result  of  pro- 
longed irritation,  such  as  that  incident  to  chronically  inflamed  tonsils, 
catarrh  of  the  mucous  membrane,  middle  ear  disease,  or  pediculi  of  the 
head. 

These  glands  may  undergo  slow  resolution  with  the  removal  of  the 
source  of  irritation,  or  may  soften,  with  practically  no  inflammatory 
phenomena  other  than  the  surrounding  induration  of  a  chronic  peri- 
adenitis, and  either  become  absorbed  or  discharge  externally.  Softening 
takes  place  before  they  reach  the  size  of  the  last  joint  of  the  thumb. 

This  chronic  lymphadenitis  resembles,  absolutely,  the  early  stages  of 
tuberculous  adenitis,  except  that  it  generally  attacks  children  under  ten 
years  of  age.     It  predisposes  to  tuberculous  infection. 

If,  after  the  cure  of  peripheral  irritation,  the  glandular  enlargement 
does  not  subside,  the  diagnosis  should  be  made  by  the  tuberculin 
test  or  by  excision. 

Tuberculous  Lymphadenitis. — ^Tuberculous  lymphadenitis  is  char- 
acterized by  the  slow  (months),  painless  enlargement  of  usually  an 
associated  group  of  glands,  at  times  all  the  glands  of  the  neck.  This 
enlargement  may  remain  for  a  long  period  hyperplastic  in  type.  It 
may  soften  and  discharge  thin  curdy  pus  through  a  ragged  non-indurated 
sinus,  or  it  may  extensively  invade  the  periglandular  tissues,  forming 
an  infiltrated,  nodular  mass  discharging  through  many  sinuses.  It  is 
commonest  in  the  second  and  third  decades  of  life,  and  is  usually 
observed  in  the  upper  superficial  or  deep  cervical  group  of  glands 
from  which  it  extends  downward.  The  tonsil  is  the  common  port  of 
entrance,  and,  though  in  the  early  stage  (weeks)  there  will  be  found 
on  palpation,  perhaps,  not  more  than  two  or  three  smooth,  movable, 
ovoid  nodules,  the  longest  less  than  the  size  of  the  last  joint  of  the  thumb, 
at  the  time  these  patients  are  seen  by  the  surgeon  the  entire  side  of 
the  neck  may  be  found  occupied  by  a  nodular  infiltration  containing 
upward  of  a  hundred  diseased  glands. 

Tuberculous  glands  cannot  be  distinguished  from  simple  inflamma- 


THE  NECK  313 

tory  hyperplasia  in  the  earhest  period  of  their  course.  The  persistence 
of  a  chronic  enlargement  after  removal  of  the  focus  of  infection,  par- 
ticularly its  increase  in  size,  and  the  progressive  involvement  of  asso- 
ciated lymphatic  glands,  occurring  in  one  of  tuberculous  heredity  or 
environment,  would  strongly  suggest  the  nature  of  the  affection. 

Early  diagnosis  is  important  since  operation  on  advanced  cases  shows 
not  more  than  75  per  cent,  of  cures.  Moreover,  lymphosarcoma  and 
malignant  lymphoma  and  tuberculous  lymphoma,  all  present  precisely 
the  clinical  picture  of  simple  inflammatory  hyperplasia  in  their  begin- 
nings. The  diagnosis  should  be  by  excision  and  microscopic  exami- 
nation. 

Malignant  Lymphoma. — Malignant  lymphoma  is  characterized  by  hyper- 
plasia, unattended  by  inflammatory  phenomena  or  characteristic  blood 
change  except  that  common  in  all  lymphatic  hypertrophy  (eosinophilia). 
It  is  common  in  children  and  comparatively  young  people.  It  begins 
in  the  neck,  ultimately  involving  all  the  glands  of  both  sides  in  a  growth 
at  first  slow,  then  at  an  interval  varying  from  months  to  years,  becoming 
suddenly  rapid  and  progressive.  Glands  elsewhere  may  or  may  not  be 
involved. 

The  affection  is  marked  by  intermittent  fever  lasting  from  one  to 
three  weeks,  coming  and  going  without  cause.     The  anemia  is  toxic. 

In  some  cases  tuberculous  adenitis  pursues  precisely  the  course  of 
malignant  lymphoma. 

Lymphatic  Leukemia. — Lymphatic  leukemia  exhibits  similar  symptoms 
together  with  an  enormous  increase  in  the  blood  leukocytes. 

Lymphosarcoma.— Lymphosarcoma  often  begins  in  a  gland  which 
has  been  previously  enlarged  and  indolent  for  a  long  time.  It  is 
characterized  by  the  rapid  growth  of  a  single  gland,  thus  simulating 
the  early  stage  of  malignant  lymphoma.  The  size  of  the  original 
tumor  steadily  progressing,  it  breaks  through  its  capsule,  infiltrating 
the  surrounding  parts  and  is  likely  to  ulcerate  through  the  skin  by 
pressure  or  infiltration.     The  associated  chain  of  glands  is  not  involved. 

A  huge  soft  tumor,  occupying  the  side  of  the  neck,  fungating,  and 
with  metastases,  may  readily  be  called  sarcoma,  but  this  is  no  longer 
helpful  to  the  patient. 

The  rapid  (weeks)  and  causeless  increase  in  the  size  of  a  chronically 
hyperplastic  gland,  or  one  previously  healthy,  should  suggest  immediate 
removal  for  diagnostic  purposes.  This  rule  should  be  imperative  if 
the  gland  has,  when  first  seen,  reached  the  size  of  a  pigeon's  egg  with- 
out signs  of  inflammation  or  softening. 

Carcinoma. — Carcinoma  of  the  neck  is  practically  always  secondary, 
though  there  is  a  primary  form  developing  from  a  branchogenic  cyst 
(rare).  Exceptionally  the  disease  develops  primarily  in  the  thyroid  or 
the  thymus.  In  any  event,  the  presence  of  a  hard,  infiltrating  tumor 
of  the  neck,  at  first  non-inflammatory  in  type,  suggests  a  most  careful 
search  of  the  area  drained  by  the  lymphatic  glands  involved.  This 
must  include  the  nose,  mouth,  pharynx,  larynx,  and  esophagus. 

In  its  earliest  stage,  carcinoma  simulates  inflammatory  hyperplasia. 


314 


THE  HEAD,  FACE,  AND  NECK 


It  is  at  this  stage  that  the  diagnosis  should  be  formulated  by  removal 
of  the  glands  and  microscopic  examination. 

The  late  stage  is  characterized  by  areas  of  softening,  the  formation 
of  multiple  f ungating  sinuses  discharging  from  the  extensive  induration, 
and  the  progressive  involvement  of  the  glands  toward  the  thorax. 

In  the  case  of  an  extensive  infiltration,  often  bilateral  and  riddled 
with  sinuses,  the  diagnosis  between  actinomycosis,  tuberculosis,  and 
malignant  growth  may  be  difficult.  It  may  be  established  by  find- 
ing the  ray  fungus,  by  no  means  |^easy;  by  the  discovery  of  the  tubercle 


Fig.  113 


Carcinoma  of  lymph  glands.  Slow  development  during  a  year  after  destruction  with  '  'cancer 
paste"  of  an  epithelioma  of  the  lower  lip.  Tumor  indurated,  nodular  and  adherent  to  skin  and 
adjacent  structures. 

bacillus,  often  difficult  or  impossible  from  the  discharges  alone;  by 
the  excision  and  microscopic  examination  of  a  portion  of  the  growth. 
Even  this  is  not  always  absolutely  conclusive.  Cervical  carcinoma 
of  this  type  is  practically  always  secondary  to  a  primary  focus. 

Actinomycosis. — Actinomycosis  of  the  neck  is  secondary  to  that  of 
the  jaw. 

Vascular  Goitre. — Vascular  goitre  may  give  thrill,  bruit,  and  expansile 
pulsation,  and,  if  it  involve  an  aberrant  lobe  laterally  placed,  may  closely 


THE  NECK 


315 


simulate  an  aneurysm.  It  can,  however,  be  lifted  away  from  the  carotid 
artery,  does  not  affect  the  time  and  tension  of  the  pulse  distal  to  the 
tumor,  and  is  usually  associated  with  symptoms  of  Graves'  disease. 

The  Carotid  Body. — The  carotid  body,  a  small  ductless  gland  of  un- 
known function,  placed  at,  or  near,  the  bifurcation  of  the  carotid 
artery,  vascularized  from  this  and  closely  adherent  to  it,  when  enlarged 
exhibits  a  pulsation  so  pronounced  as  to  suggest  aneurysm.     Tumor 

Fig.  114 


Bilobular  lipoma.    Twenty-five  years'  duration;  freely  movable;  doughy  consistence,  not  connected 
with  thyroid;  skin  dimples  when  made  tense;   travelled  downward  from  the  neck.    (Carnett.) 


of  the  carotid  body  arises  from  the  region  of  bifurcation  of  the  com- 
mon carotid  artery  beneath  the  sternomastoid  muscle  about  the  level 
of  the  upper  border  of  the  thyroid  cartilage.  It  is  moderately  movable 
horizontally,  but  not  vertically.  It  is  usually  ovoid  in  shape,  is  smooth 
and  not  lobulated,  is  single  and  not  made  up  by  the  coalescence  of 
several  tumors,  exhibits  transmitted  but  not  expansile  pulsation,  may 


316 


THE  HEAD,  FACE,  AND  NECK 


give  both  bruit  and  thrill,  may  cause  bulging  of  the  wall  of  the  pharynx, 
occasionally  contracts  the  pupil  of  the  same  side,  grows  slowly  at  first, 
then  rapidly,  exists  for  a  number  of  years  before  causing  trouble,  and 
is  moderately  dense  in  consistence.  Inflammatory  and  subjective  symp- 
toms are  usually  absent.  The  difficulty  encountered  in  its  extirpation 
makes  the  diagnosis  important. 

The  pulsation  of  a  cold  abscess  placed  close  to  the  carotid  artery 
may  so  closely  simulate  that  of  aneurysm  as  to  require  the  use  of  an 
exploratory  needle  for  the  formulation  of  a  diagnosis. 

Syphilitic  Adenopathy. — ^The  early  stages  of  the  disease  are  character- 
ized by  a  moderate  hyperplasia  particularly  of  the  postcervical  group 
of  glands. 


Fig.  115 


Lipoma  of  neck.     Common  situation;  soft,  semifiuctuating;  skin  normal. 


Gummatous  adenopathy  of  the  neck  is  extremely  rare.  Gummata  of 
the  skin  and  subcutaneous  tissues  of  the  back  of  the  neck  are  fairly 
common,  and  are  characterized  by  skin  infiltration  followed  by  early 
softening  (weeks)  and  the  formation  of  one  or  more  deep,  punched- 
out  ulcers.  The  diagnosis  must  be  made  from  epithelioma  (rare)  by 
associated  lesions  of  syphilis,  and  by  the  rapid  course,  absence  of  enlarged 
glands,  and  the  characteristic  resultant  ulcer. 

Lipoma. — Lipoma,  commonest  in  the  back  of  the  neck,  forms  a  clearly 
outlined,  slowly  growing  tumor,  which,  until  it  has  reached  large  size, 
closely  resembles  a  sebaceous  cyst. 


THE  NECK 


317 


The  diffuse  form  of  lipoma,  noted  in  middle-aged  working  men,  not 
otherwise  fat,  appears  in  the  form  of  huge,  double  chins,  supraclavicular 
pads,  and  great  bosses  on  the  back  of  the  neck  which  may  penetrate  the 
deep  fascia.  The  diffuse,  subfacial  lipoma  is  often  congenital,  and 
hence  may  be  seen  in  children  as  well  as  in  adults.  It  penetrates  mus- 
cular interspaces  deeply,  sending  prolongations  along  the  line  of  least 
resistance.     It  often  gives  the 

sensation  of   a  cystic   growth.  Fig.  iie 

Its  nature  can  be  determined 
by  operation. 

Fibroma. — Fibroma,  if  super- 
ficial and  circumscribed,  arises 
from  the  nerves  (neurofibroma) 
or  bloodvessels  (angiofibroma) 
of  the  skin  and  subcutaneous 
tissue,  presenting  the  appear- 
ance o^  fibroma  molluscum.  The 
diffuse,  superficial  form  appears 
as  an  elephantiasis. 

The  deep  form,  having  for  its 
seat  of  predilection  the  back 
of  the  neck,  but  developing 
elsewhere,  is  characterized  by 
density  of  structure  and  slow 
growth. 

Affections  Characterized  by 
Fluctuating,  Non  -  iniaamma- 
tory  Tumor. — Branchial  Cysts. 
— Branchial  cysts,  usually  de- 
veloping after  puberty,  are  the 
remains  of  the  thyroglossal 
duct  and  the  second  branchial 
cleft.  In  the  latter  case  they 
are  placed  at  first  along  the 
anterior  border  of  the  sterno- 
mastoid  muscle.  They  may 
form  large,  soft  tumors  occupy- 
ing the  greater  part  of  the  an- 
terolateral cervical  region.  The  growth  is  slow  and  non-inflammatory, 
giving  pain  or  discomfort  only  on  pressure.  Such  a  fluctuating  growth 
developing  in  an  adult,  and  not  preceded  by  a  solid  tumor,  can  scarcely 
be  other  than  a  branchial  cyst.  Because  of  their  close  relation  to  the 
vessel  sheaths  the  removal  of  the  cysts  may  be  difficult. 

The  cyst  due  to  an  unobliterated  thyroglossal  duct  is  found  in  the 
midline,  between  the  sternal  notch  and  the  foramen  cecum  at  the  base 
of  the  tongue.  It  can  be  distinguished  from  subhyoid  or  suprahyoid 
bursa  only  by  microscopic  examination  of  its  contents. 


Suppurating  branchial  cyst.  Man,  aged  forty- 
three  years;  duration  four  months;  slight  tender- 
ness; occasional  discomfort  on  swallowing;  firm,  ill- 
defined,  non-fluctuating  mass,  closely  connected  with 
surrounding  tissue.  Overlying  skin  normal  and 
freely  movable;  regional  lymph  nodes  not  involved. 
Diagnosis,  microscopic.     (Frazier.) 


318 


THE  HEAD,  FACE,  AND  NECK 


Dermoids. — Dermoids  form  small,  soft,  subcutaneous  tumors  of  slow 
growth,  usually  in  the  anterolateral  region  of  the  neck,  developing  after 
infancy.     The  diagnosis  can  be  made  only  by  excision. 

Congenital  Serous  Cysts. — Congenital  serous  cysts,  usually  observed  in 
infants  at  birth,  are  due  to  dilatation  of  the  lymphatic  vessels.  They  are 
multilocular,  filled  with  serum  which  coagulates  on  being  drawn,  are 
sometimes  discolored  by  blood,  have  no  distinct  capsule,  and  penetrate 
deeply  and  intimately  among  the  various  structures  of  the  neck,  much  as 
does  a  lipoma.  These  cysts  begin  along  the  inner  and  outer  margin  of 
the  sternomastoid,  and  increase  in  size,  often  rapidly,  forming  large,  soft, 
fluctuating,  at  times  semitranslucent  tumors,  which  may  occupy  the 
entire  side  of  the  neck  and  bulge  into  the  axilla.  The  loculation  and 
varying  consistency  and  the  presence  of  fibrous  bands  in  these  cysts  is 
characteristic. 

Fig.   117 


Subcutaneous  cavernous  angioma.  Slightly  elevated  compressible  tumor  of  indefinite  outlines 
on  left  front  of  neck,  simulating  a  fibrolipoma  on  palpation;  slow  growth  since  early  childhood; 
possesses  erectile  properties  as  shown  by  comparison  with  accompanying  photograph  (Fig.  118) 
taken  after  prolonged  expiratory  straining  effort  with  glottis  closed.     (Carnett.) 

Blood  Cysts. — Blood  cysts  of  congenital  origin  may  not  develop  until 
late  in  life.  They  form  soft  tumors  often  communicating  directly  with 
large  veins,  sometimes  made  up  of  a  mass  of  varices  which  may  attain 
a  size  so  large  as  to  involve  the  whole  side  of  the  neck,  reach  to  the 
axilla  and  extend  down  the  anterior  wall  of  the  chest.     The  tension 


THE  NECK 


319 


of  these  cysts  is  increased  by  straining  efforts^  and  they  can  be  partly 
emptied  of  their  contents  by  surface  pressure.  They  do  not  pulsate. 
There  is  often  an  overlying  skin  angioma.  Aspiration  may  be  needful 
for  diagnosis. 

Sebaceous  Cysts. — Sebaceous  cysts  form  indolent,  at  first  hard,  tumors, 
the  natiu-e  of  which  is  suggested  by  the  distinctly  rounded  form,  super- 
ficial position,  close  adhesion  to  the  skin,  and  often  the  enlarged  duct 
entrance  from  which  can  be  squeezed  the  sebaceous  matter.  They  are 
commonly  placed  at  the  back  of  the  neck  near  the  hair  line.  Lipoma 
similarly  placed  may  present  most  of  the  same  characteristics. 

Fig.  lis 


Subcutaneous  cavernous  angioma.  Same  case  as  Fig.  117  during  expiratory  straining;  tense, 
soft  swelling  sliowing  slight  lobulation  but  no  discoloration  of  skin;  scar  from  an  exploratory 
operation  during  childhood;  percussion  note  higher  pitched  than  opposite  side,  but  tympanitic 
from  underlying  air  passages;  spontaneous  subsidence  of  swelling  on  cessation  of  straining  effort. 
(Camett.) 


Subhyoid  Bursa.— Subhyoid  bursa  develops  slowly  and  indolently 
beneath  the  hyoid  bone,  and  cannot  be  distinguished  from  a  cyst  of  the 
th}Toglossal  duct  or  an  accessory  thyroid  excepting  by  operation. 
The  suprahyoid  bursa  is  indistinguishable  from  accessory  thyroid  in  this 
position  or  overdevelopment  of  the  lingual  tonsil,  since  it  may  be  impos- 
sible to  elicit  fluctuation. 

Chronically  Inflamed  Glands. — ^At  times  glands  hyperplastic  either  from 
long- continued   simple   irritation  or  from  tuberculous   affection,  form 


320 


THE  HEAD,  FACE,  AND  NECK 


fluctuating  tumors  entirely  wanting  in  all  the  obvious  signs  of  inflamma- 
tion. These  tumors  are,  as  a  rule,  multiple  rather  than  single,  are  sur- 
rounded by  the  induration  of  a  chronic  periadenitis,  and  will  be  found  to 
have  developed  at  the  seat  of  former  hard  nodules. 

Sarcoma.— Sarcoma  may  become  so  markedly  cystic  as  to  obscure  on 
examination  the  solid  elements  of  the  growth.  This  is,  as  a  rule,  a  late 
development,  and  follows  at  the  seat  of  a  solid  or  semisolid  infiltration. 

Cystic  Goitre. — Cystic  goitre  usually  gives  the  characteristic  signs  of  its 
thyroid  origin.  When  an  aberrant  lobe  undergoes  cystic  degeneration, 
the  diagnosis  may  be  impossible  without  operation. 

Fig.  119 


Cystic  goitre.     Duration,  years.     No  subjective  symptoms. 


Lipoma. — Lipoma  which  may  be  superficial  or  deep,  circumscribed 
or  diffuse,  usually  presents  such  characteristic  features  that  the  diag- 
nosis is  obvious.  It  may,  however,  especially  when  placed  beneath 
the  fascia,  appear  as  a  somewhat  irregularly  outlined  tumor,  giving 
a  sense  of  fluctuation  so  distinct  as  to  deceive  the  elect.  It  is  not  infre- 
quently combined  with  congenital  serous  cysts.  In  doubtful  cases  the 
diagnosis  can  be  made  only  by  operation. 

Affections  Characterized  by  Pulsating  Tumor. — Anemysm. — ^Any 
tumor  of  the  neck  placed  near  a  large  artery  may  exhibit  transmitted 
pulsation.  When  this  pulsation  is  of  the  expansile  type,  is  associated 
with  thrill  and  bruit,  is  placed  in  the  course  of  an  artery,  and  the  pulse  in 


THE  NECK  321 

this  artery  and  its  branches  distal  to  the  tumor  is  slowed  and  lessened  in 
tension,  the  tumor  is  necessarily  an  aneurysm.  The  tumor  may  be  formed 
by  the  locally  dilated  wall  of  the  artery  (true  aneurysm)  weakened  by 
syphilitic  or  alcoholic  arteritis,  or  by  a  condensation  of  fibrous  tissue 
adjacent  to  the  wall  (traumatic). 

The  artery  involved  is  usually  the  common  carotid.  Aneurysm  of  this 
vessel  exhibits  less  of  a  sex  predilection  than  is  noted  elsewhere,  though 
it  is  more  common  in  men  than  in  women.  It  may  be  associated  with 
aneurysmal  dilatation  of  other  regions. 

In  addition  to  the  t\"pical  symptoms  of  aneurysm  (see  p.  98),  there 
are  highly  characteristic  pressure  symptoms  expressed  in  the  form  of 
vertigo,  syncope,  and  either  somnolence  or  insomnia,  pain  referred  along 
the  brachial  plexus,  hoarseness  of  the  voice,  dilatation  of  the  pupil, 
dyspnea  and  dysphagia,  sometimes  unilateral  palsy,  and  atrophy  of  the 
tongue. 

In  the  aged,  especially  those  who  are  emaciated,  there  is  commonly 
a  fusiform  dilatation  of  the  carotid  at  its  point  of  bifurcation,  causing  a 
palpable  tumor  with  an  expansile  pulsation  so  marked  as  strongly  to 
suggest  aneurysm.  There  is  no  thrill,  but  an  artificial  bruit  may  be 
caused  by  even  slight  pressure  of  a  stethoscope. 

Aneurysm  of  the  internal  carotid  (rare)  forms  a  pulsating  tumor  which 
projects  into  the  pharynx. 

An  aneurysm  of  the  external  carotid  is  usually  traumatic  in  origin, 
and  exhibits  the  characteristic  features  of  this  affection. 

Aneurysm  of  the  subclavian  artery  forms  a  transversely  elongated 
tumor  projecting  above  the  clavicle  at  the  outer  side  of  the  stern  ©mastoid, 
its  bruit  is  carried  into  the  axillary  artery,  and  this  vessel,  together  with 
the  radial,  shows  a  slowed  and  softened  pulse  as  compared  with  the 
corresponding  vessels  of  the  healthy  side. 

Aneurysm  of  the  innominate  artery  forms  a  tumor  projecting  behind 
the  sternoclavicular  articulation  and  often  palpable  at  the  suprasternal 
notch;  its  bruit  is  carried  by  both  the  carotid  and  subclavian,  and  both 
those  vessels  exhibit  the  characteristic  pulse  alterations.  As  in  all 
aneurysms,  pressure  symptoms  are  well  marked  and  are  expressed  by 
venous  engorgement,  muscular  spasm  or  palsy,  pain,  bone  erosion,  altera- 
tion of  the  voice,  cough,  dyspnea,  and  dysphagia.  The  right  recurrent 
laryngeal  nerve  is  usually  involved. 

x\neurysm  of  the  aorta  exhibits  little  tendency  to  extend  upward  into 
the  neck.  The  symptoms  due  to  pressure  upon  the  brachial  plexus  and 
the  veins  are  left-sided.  The  presence  of  this  timior  may  be  determined 
by  the  pressure  symptoms,  tracheal  tug,  the  results  of  auscultation  and 
percussion,  and  finally  by  the  .T-rays. 

Arteriovenous  aneurysm  of  the  neck  is  usually  traimiatic  and  extremely 
rare.     It  exhibits  the  characteristic  sjTnptoms. 


21 


322  THE  HEAD,  FACE,  AND  NECK 


THE  LARYNX. 

The  symptoms  common  to  affections  of  the  larynx  are  pain,  alteration 
of  the  voice,  cough,  and  difficulty  in  breathing. 

The  pain  is  felt  in  the  larynx  and  may  be  aggravated  by  swallowing 
or  speaking.  Except  it  be  neurotic,  it  is  usually  expressive  of  infiltration 
or  inflammation. 

Alteration  of  voice  is  characterized  by  difficulty  in  striking  the  true  note 
in  the  case  of  singers,  by  hoarseness,  or  by  complete  loss  of  the  spoken 
voice. 

Cough  due  to  laryngeal  irritation  is,  in  the  absence  of  an  ulcerating 
lesion,  harassingly  recurrent  and  fruitless.  A^Tien  it  is  symptomatic 
of  trauma  or  of  ulcerative  lesions,  it  is  accompanied  by  an  expectoration 
of  bloody  or  sanguinopurulent  mucus. 

Respiratory  obstruction,  if  slight,  is  marked  only  by  noisy  breathing. 
In  the  severe  form  there  is  cyanosis  and  mental  perturbation,  and  the 
noisy  breathing  is  accompanied  by  violent  inspiratory  efforts  and 
retraction  of  the  suprasternal  notch  and  the  intercostal  spaces  with 
each  inspiratory  effort. 

Edema  of  the  Glottis. — ^This  is  expressed  by  a  swelling  of  the  ary- 
epiglottic  folds  and  base  of  the  epiglottis,  narrowing  or  occluding  the 
superior  laryngeal  orifice,  and  is  a  common  expression  of  acute  inflam- 
mation of  the  tongue,  throat,  tonsils,  or  laryngeal  mucosa,  and  of 
laryngeal  trauma.  It  occurs  as  a  part  of  a  general  edema,  may  be 
secondary  to  tumor  pressure,  and  is  an  occasional  dangerous  expression 
of  angioneurotic  edema. 

The  symptoms  are  those  of  laryngeal  obstruction.  The  diagnosis,  if 
not  obvious,  is  made  by  a  laryngoscopic  examination. 

Contusion. — Contusion  of  the  larynx  is  characterized  by  violent  cough, 
dyspnea ,  and  aphonia,  exceptionally  by  sudden  death,  apparently  due  te 
cardiac  inhibition. 

The  diagnosis  of  contusion  will  be  based  upon  the  failure  to  elicit  the 
symptoms  of  fracture  by  external  manipulation.  Laryngoscopic  exami- 
nation may  show  swelling  or  even  blood  extravasation,  and  limitation 
of  motion  of  the  vocal  cords.  The  aphonia  which  frequently  results  is 
usually  transitory. 

Fracture. — Fracture  of  the  larynx,  due  to  direct  force,  commonly 
involving  the  thyroid,  and  appearing  as  a  median  or  lateral  vertical 
break,  is  characterized  by  dyspnea,  usually  dangerous  in  its  intensity, 
cough,  often  with  bloody  expectoration,  and  aphonia.  The  diagnosis 
is  based  upon  deformity,  which  is  usually  obvious,  preternatural  mobility, 
and  crepitation  readily  elicited  except  in  case  of  simple  fissures  or  of 
fracture  with  wide  displacement,  swelling,  tenderness  and  often  the  fine 
crepitation  of  emphysema.  The  laryngoscopic  examination  shows 
blood  extravasation. 

Tracheal  fracture  due  to  direct  violence,  sometimes  to  overstretching, 
or  to  violent  coughing,  and  often  associated  with  laryngeal  fracture, 


THE  LARYNX  323 

usually  appears  in  the  form  of  a  transverse  tear,  which  may  be  com- 
plete. Profound  dyspnea,  rapid  emphysema,  pain,  cough,  and  bloody 
expectoration  are  the  symptoms  which  suggest  the  diagnosis. 

Bums  or  Scalds. — Burns  or  scalds  of  the  larynx,  if  not  immediately 
fatal  from  cardiac  inhibition,  cause  the  dyspnea  and  aphonia  of  rapid 
edema. 

Foreign  bodies  of  the  larynx  are  characterized  by  the  sudden  onset  of 
violent  cough  and  dyspnea. 

Usually  the  body  is  extruded  by  the  first  coughing  act.  It  may, 
however,  become  lodged  in  the  larynx,  remain  movable  in  the  trachea 
or  pass  into  one  of  the  bronchial  tubes,  usually  the  right,  and  remain 
fixed  there. 

If  the  body  be  lodged  in  the  larynx  and  not  of  sufficient  size  to  entirely 
obstruct,  it  causes  recurring  paroxysmal  cough.  There  is  a  temporary 
amelioration  of  the  spasmodic  dyspnea  after  the  accident,  followed 
shortly  by  increased  difficulty  in  breathing  incident  to  edema. 

If  the  body  be  loose  in  the  trachea,  it  causes  recurring  violent  paroxysms 
of  cough  and  dyspnea  similar  in  violence  and  suddenness  of  onset  to 
that  characteristic  of  the  first  insufflation. 

Lodgement  in  a  bronchus  is  marked  by  pain  in  one  side  of  the 
chest,  alteration  in  the  respiratory  murmur  of  the  blocked  lung,  and 
whistling  or  wheezing  at  the  point  of  lodgement. 

Diagnosis  as  to  the  seat  of  the  body  is  based  upon  the  history  of  the 
case,  laryngoscopic  examination,  the  use  of  the  bronchoscope,  and, 
where  this  is  applicable,  the  a;-rays. 

Inflammation. — Laryngitis. — ^Acute  laryngitis  is  characterized  by  pain 
on  swallowing  or  even  speaking,  referred  to  the  larynx,  usually  cough 
and  hoarseness  or  loss  of  voice. 

In  its  acute  congestive  form  it  is  exemplified  by  the  croup  of  chil- 
dren. There  is  usually  here  an  associated  spasm.  Diagnosis  is  based 
upon  the  usual  preceding  slight  catarrh,  suddenness  of  the  attack  and 
its  rapid  disappearance. 

Diphtheritic  laryngitis  causes  obstruction  both  by  edematous  swelling 
and  the  inflammatory  exudate.  The  diagnosis  is  based  upon  the 
presence  of  the  membrane  containing  the  specific  microorganisms. 

Laryngismus  stridulus  is  characterized  by  an  inspiratory  arrest  after 
a  few  straining  noisy  breathing  efforts,  followed  by  cyanosis  and  shortly 
the  resumption  of  normal  breathing.  As  it  is  purely  spasmodic,  the 
attack  is  sudden  in  onset  and  is  neither  preceded  nor  followed  by  the 
symptoms  of  a  laryngeal  catarrh. 

Perichondritis. — ^Perichondritis,  usually  secondary  to  gumma,  typhoid 
fever,  intubation,  or  tuberculous  or  malignant  infiltration,  is  character- 
ized by  abscess  formation,  with  exposure  or  discharge  of  dead  cartilage, 
often  followed  by  stricture.  Sometimes  the  rings  of  the  trachea  are 
involved.  The  larynx  may  be  obstructed  during  the  suppurative  stage 
or,  after  healing,  incident  to  scar  formation. 

The  characteristic  symptoms  are  alteration  of  the  voice,  dyspnea, 
and  the  discharge  of  pus  from  an  abscess  covering  dead   cartilage. 


324  THE  HEAD,  FACE,  AND  NECK 

When  the  abscess  points  externally,  diagnosis  is  not  difficult.  When 
it  points  internally,  the  early  symptoms  are  those  of  obstruction. 

The  diagnosis  of  obstruction,  when  this  occurs  to  an  alarming  extent, 
is  obvious,  but,  since  the  inflammation  may  be  subacute  or  chronic,  and 
attended  with  few  symptoms,  a  recognition  of  the  cause  of  obstruction 
is  usually  dependent  upon  laryngoscopic  examination  when  this  is 
possible,  and  a  consideration  of  the  fact  that  perichondritis  in  its 
obstructive    form  is   usually  syphilitic  or  typhoidal,  or  post-typhoidal. 

Tuberculosis. — Tuberculosis  of  the  larynx  is  characterized  by  the 
chronicity  of  the  inflammatory  process.  It  is  common  in  young  adults, 
is  often  unilateral,  and  attacks  by  preference  that  side  on  which  the 
lung  is  principally  involved.  It  is  nearly  always  secondary  to  tuberculosis 
of  the  lungs. 

The  characteristic  symptoms  are  alteration  of  the  voice,  cough, 
difficulty,  often  pain,  in  swallowing,  so  great  as  to  interfere  with  the 
patient's  nourishment,  and  the  presence  of  ulcerating  infiltrations,  par- 
ticularly of  the  posterior  wall  of  the  larynx,  the  arytenoid  cartilages 
and  the  epiglottic  folds. 

The  diagnosis  from  malignant  disease  is  made  by  examination  for  the 
tubercle  bacilli,  and  association  of  these  ulcers  with  other  tuberculous 
lesions. 

Lupus. — Lupus  is  usually  secondary.  It  has  been  described  as  form- 
ing papillomatous  and  ulcerating  patches. 

Syphilis. — Syphilis,  in  its  secondary  stage,  may  appear  in  the  form 
of  mucous  patches,  and  by  a  complicating  edema  may  threaten  life. 

Gummatous  infiltration  forms  one  or  more  tumors  which  ulcerate 
before  reaching  the  size  of  a  gooseberry.  The  usual  expression  of  late 
syphilis  is  in  the  form  of  a  disseminated  infiltration  involving  the  peri- 
chondrium and  ulcerating  in  patches.     The  trachea  is  rarely  attacked. 

The  diagnosis  is  formulated  on  change  of  voice  or  its  loss,  purulent 
blood-stained  expectoration,  usually  little  pain  (exceptionally  severe)  on 
swallowing,  the  detection  of  ulceration  and  infiltration  on  examina- 
tion, the  therapeutic  test  and  excision  and  examination  of  a  portion  of 
the  infiltrate. 

Stenosis  of  the  Larynx  and  Trachea. — Stenosis  of  the  larynx  and  tra- 
chea may  be  secondary  to  any  ulcerative  or  destructive  process.  Trau- 
matism, syphilis,  and  the  perichondritis  of  infectious  fevers,  particularly 
typhoid,  are  the  common  causes.  Tracheotomy,  with  subsequent  long- 
continued  wearing  of  the  tracheal  tube,  is  the  usual  form  of  traumatism. 

The  characteristic  symptoms  are  alterations  in  the  voice,  dyspnea, 
and  noisy  respirations.  When  the  stenosis  is  due  to  external  pressure,,  as 
from  an  enlarged  thyroid,  aneurysm,  or  cervical  or  mediastinal  tumor, 
auscultation  will  usually  detect  the  seat  of  stridor,  there  will  be  signs 
of  a  mass  in  the  neck  or  thorax,  and  the  laryngoscope  will  show  a  clear 
laryngeal  opening.  There  may  be  multiple  strictures  of  the  larynx  and 
trachea. 

Laryngeal  Fistulae. — These,  when  secondary  to  wound  or  necrosis 
of  the    cartilage    opening   externally,  are  readily   recognized.     When 


THE  THYROID  325 

opening  into  the  esophagus,  usually  secondary  to  the  ulceration  of 
a  foreign  body  or  a  carcinomatous  infiltration,  they  are  attended  by 
the  coughing  up  of  ingested  food.  Gerhardt  passes  a  tube  into  the 
esophagus  not  quite  to  the  supposed  seat  of  fistula.  Through  this  tube 
the  patient  can  force  air  by  expiratory  effort,  as  shown  by  holding  its 
external  end  under  water. 

Paralysis  of  the  Recurrent  Laryngeal  Nerve. — Paralysis  of  the  recurrent 
laryngeal  nerve,  earliest  evidenced  in  the  abductor  muscles  of  the  aryte- 
noids, leaves  the  vocal  cords  in  a  midline  position,  and,  if  bilateral, 
occasions  inspiratory  dyspnea.  Unilateral  involvement  may  be  without 
symptoms  other  than  alteration  of  voice.  Diagnosis  is  made  by  laryngo- 
scopic  examination.  Unilateral  palsies  are  often  significant  of  innomi- 
nate aneurysm,  mediastinal  tumor,  or  malignant  growth. 

Tumors  of  the  Larynx.- — Tumors  of  the  larynx  are  generally  benign. 
Of  this  class,  fibroma  and  papilloma  are  the  usual  ones.  Fibroma 
rises  from  the  vocal  cords  of  adults,  forming  small,  rounded,  pedunculated 
or  sessile  growths  (years). 

Papilloma,  often  multiple,  presents  a  characteristic  warty  appear- 
ance, attacking  the  vocal  cords  by  preference.  Papillomata  may  be 
single,  grouped,  or  multiple  and  disseminated.  They  are  commonly 
observed  before  middle  life. 

Retention  cysts  and  angiomata  have  been  observed. 

The  characteristic  symptoms  of  benign  tumor,  if  it  gives  any,  are 
alterations  of  the  voice,  and  the  evidences  of  a  persistent  or  recurring 
slight  laryngitis.  Exceptionally  there  is  dyspnea.  The  diagnosis  is 
based  upon  the  findings  of  a  laryngoscopic  examination,  excision,  and 
microscopic  examination. 

Malignant  Tumors. — Sarcoma  attacks  men  of  early  middle  age.  In 
its  beginning  stage  it  cannot  be  distinguished  from  fibroma.  Its  seats  of 
predilection  are  the  bone  and  false  cords  and  the  epiglottis.  It  is  not 
prone  to  ulcerate  or  give  glandular  metastases.  Its  rapid  growth 
(months)  is  characteristic. 

Carcinoma  develops  in  the  middle  aged  and  old  (fortieth  to  the 
eightieth  year),  exhibiting  a  predilection  for  men.  The  disease  is 
characterized  by  an  infiltration  which  may  slowly  spread  as  such. 
Commonly  it  ulcerates. 

Involvement  of  surrounding  structures  and  glandular  metastases  are 
earliest  observed  in  cancer  of  the  vestibule. 

The  early  symptom  of  malignant  tumor  of  the  larynx  is  change  in 
voice.  The  diagnosis  is  based  upon  laryngoscopic  examination  by  which 
the  presence  or  absence  of  tumor  may  be  determined.  The  nature 
of  the  tumor,  unless  it  be  unmistakably  benign  (papilloma  in  a  young 
person),  should  be  determined  by  removal  and  microscopic  examina- 
tion. 

THE  THYROID. 

The  thyroid,  a  highly  vascular,  ductless  gland,  is  made  up  of  two" 
lateral  lobes  placed  on  either  side  of  the  trachea  and  thyroid  cartilage. 


326  THE  HEAD,  FACE,  AND  NECK 

and  an  isthmus  connecting  these  two  by  passing  across  the  front  of  the 
trachea.  Each  lateral  lobe,  about  two  inches  long,  extends,  with  the 
head  in  its  normal  position,  from  the  middle  of  the  thyroid  cartilage 
to  within  half  an  inch  of  the  top  of  the  sternum.  The  isthmus,  about 
half  an  inch  wide,  lies  in  front  of  the  second,  third,  and  fourth  tracheal 
rings.  From  it  there  is  an  upward  extension,  called  the  pyramidal  lobe, 
a  remnant  of  the  thyroglossal  duct,  from  which  are  developed  the 
accessory  thyroids,  found  in  the  region  of  the  hyoid  bone  or  in  the  base 
of  the  tongue.  There  are  other  accessory  glands  having  slight  connec- 
tion or  none  at  all  with  the  thyroid,  the  commonest  position  of  which  is 
behind  the  sternum.  The  thyroid  may  completely  encircle  the  trachea, 
pass  behind  the  esophagus,  or  by  its  accessory  lobes  extend  laterally 
into  the  neck.  It  varies  considerably  in  size,  within  normal  limits,  being 
proportionately  larger  in  infants  and  in  females  than  in  male  adults. 

Destruction  of  the  secreting  substance  of  the  thyroid,  either  by  disease 
or  operation,  is  followed  by  myxedema.  Its  congenital  absence  or 
disease  produces  cretinism.  Some  forms  of  hypersecretion  and  over- 
vascularization,  and  glandular  growth,  are  accompanied  by  Graves' 
disease. 

The  normal  thyroid  cannot  be  readily  palpated,  and  any  gland  which 
may  be  distinctly  outlined,  either  in  part  or  in  whole,  is  abnormal. 

Aside  from  the  constitutional  effect  of  its  glandular  degeneration  or 
hyperactivity,  its  enlargement  may  cause  pressure  upon  the  veins  of  the 
neck,  the  recurrent  laryngeal  nerve,  the  trachea,  or  the  esophagus, 
resulting  in  cephalic  congestion,  changes  in  the  voice,  and  dyspnea; 
dysphagia  is  rare  except  from  cancer  of  the  thyroid  or  enlargement 
of  a  post-esophageal  accessory  thyroid. 

Lying  close  to  the  thyroid  capsule,  to  the  outer  side  and  behind  the 
lateral  lobes,  each  about  the  size  of  a  small  bean,  are  the  parathyroid 
glands,  structures  so  small  as  to  escape  notice,  as  a  rule,  and  yet  fulfilling 
an  important  function,  since  the  removal  of  these  glands  in  animals 
causes  tetany.  There  is  reason  to  believe  that  the  same  result  follows 
when,  in  the  course  of  operation,  they  are  removed  in  man. 

The  cardinal  local  symptom  of  diseases  of  the  thyroid  gland  is 
tumor  in  the  thyroid  region,  attached  to  the  trachea  and  moving  with 
it  in  deglutition. 

Cretinism. — Where  goitre  is  endemic,  children  are  born  who,  because 
the  thyroid  gland  is  either  absent  or  diseased,  exhibit  characteristic 
dystrophies.  There  is  a  dwarfed  stature,  due  to  failure  of  the  long 
bones  to  develop  in  length,  though  they  reach  their  normal  thickness; 
leathery,  loose,  dry,  hairless,  pasty  skin,  an  infantile  condition  of  the 
genitalia  associated  with  sterility,  usually  idiocy,  deafness,  and  inability 
to  articulate. 

Myxedema. — Myxedema,  incident  to  removal  or  destruction  by 
disease  of  the  gland  in  adults,  does  not  affect  stature,  but  blurs  the 
features,  indeed,  all  the  body  outlines,  by  a  progressive,  non-pitting 
thickening  of  the  subcutaneous  tissues.  From  the  dry,  pasty  skin,  the 
hair  and  nails  are  shed.     The  pulse  is  slowed,  the  hemoglobin  below 


PLATE    XVI 


^v    h 


Lateral  View  of  the  Lymphatics  of  the  Tongue  Emptying  into  the  Deep 
Cervical  Lymph  Nodes,  some  perforating  and  others  passing  between  the 
genioglossi. 


PLATE  XVII 


FIG.   1 


S.P.B. 


I.P.B. 


R.L.N. 


Posterior  View  of  Thyroid  Gland.      Anastomosis  between  parathyroid 
bodies  on  both  sides. 

.4.,  anastomosis  in  posterior  surface  of  pharynx;  S.T.A.,  superior  thyroid  artery;  S.P.B. ,  superior 
parathyroid  body;  I.P.B. ,  inferior  parathyroid  body;  R.L.N. ,  recurrent  laryngeal  nerve.  Reduced  one- 
sixth  natural  size. 


FIG.  2 


S.P.B. 


P.A. 


LT.A. 


LP.B. 


S.T.A. 


Left  Thyroid  Lobe  Viewed  from  Behind.    Shows  unusual  position  and  blood  supply 
of  superior  parathyroid  body,  rendering  body  likely  of  removal  in  lobectomy. 

.S.r.^.,  superior  thyroid  artery;   5. P. S.,  superior  parathyroid  body;    P.A. ,  parathyroid  artery;    LT.A., 
inferior  thyroid  artery;    LP.B.,  inferior  parathyroid  body.     Reduced  one-sixth  natural  size. 


THE   THYROID  327 

normal,  the  mentality  dulled,  the  virility  gone.  Puberty  is  retarded, 
or  does  not  develop  when  the  thyroid  is  destroyed  before  this  period. 
These  symptoms  have  followed  partial  thyroidectomy  after  an  interval 
of  years. 

Graves'  Disease. — ^Graves'  disease  is  dependent,  in  part  at  least,  upon 
hypersecretion  or  perverted  secretion  of  the  thyroid.  Although  it  is 
true  that  experimental  lesion  of  the  central  nervous  system  (restiform 
bodies)  may  produce  all  the  symptoms  of  Graves'  disease,  these  do 
not  develop  if  previous  to  such  lesion  the  thyroid  be  removed.  More- 
over, they  are  cured  if  after  having  developed  in  consequence  of  such 
lesion  the  thyroid  be  extirpated. 

The  dominant  symptoms  of  Graves'  disease  are  thyroid  enlarge- 
ment, tenderness  and  murmur,  tachycardia,  exophthalmos  and  tremor, 
sweating,  vomiting,  diarrhea,  and  often  enlargement  of  the  lymphatic 
glands  of  the  neck.  These  may  be  present  to  a  degree  in  any  form 
of  goitre.  Palpitation  of  the  heart  is  the  most  distressing  and  dangerous 
symptom.  Soon  it  becomes  complicated  by  myocarditis,  and  may  be 
associated  with  angina  pectoris. 

Exophthalmos,  obvious  on  inspection,  is  attended  by  movement  of 
the  upper  lid,  slower  than  normal,  when  the  patient  looks  up  or  down 
(Grafe's  sign),  abnormal  width  of  the  palpebral  fissure  (Stelwag's 
sign),  and  impaired  accommodation  without  diplopia  (Moebius'  sign). 
Kocher  regards  as  an  early  important  symptom  a  leukopenia  (particularly 
of  the  neutrophilic  polymorphonuclears),  a  percentage  and  absolute 
increase  in  the  lymphocytes,  and  an  upward  flick  of  the  lid,  preceding 
by  a  distinct  interval  the  movement  of  the  eyeball  if  the  examiner's 
hand,  held  in  front  of  the  eye,  be  suddenly  raised. 

Tremor  involves  the  muscles  of  the  trunk  as  well  as  those  of  the 
extremities. 

Neurasthenia  is  aggravated  and  pronounced,  and  usually  precedes 
the  exophthalmos.  Headache  and  insomnia  are  common.  Excep- 
tionally myxedema  develops. 

Postoperative  Tetany. — ^Postoperative  tetany,  incident  to  complete 
removal  of  the  parathyroids,  closely  resembles  lockjaw.  It  has  been 
noted  immediately  after  the  etherization;  usually  within  the  first  ten 
days  of  operation.  Stiffness  in  the  legs  and  arms  is  prodromal,  as  is 
sudden  contraction  of  the  muscles  of  distribution  on  tapping  a  nerve 
trunk  (facial,  Chvostek).  It  is  characterized  by  tonic  spasm,  par- 
ticularly of  the  arm  and  forearm  muscles.  The  attack  may  pass  off 
in  a  few  minutes,  may  recur  frequently,  may  cause  death  by  spasm  of 
the  respiratory  muscles,  or  may  gradually  subside  in  violence. 

Acute  Thyroid  Congestion.- — Enlargement  of  the  thyroid  gland,  rapid 
in  onset,  usually  transient,  may  occur  in  females  at  puberty  or  at  any  time 
during  the  period  of  pregnancy  and  parturition.  It  is  characterized  by 
slight  heat,  enlargement  sufficient  to  become  palpable  and  often  visible, 
possibly  some  tenderness,  and  tendency  to  shortness  of  breath. 

Acute  Thyroiditis. — Either  the  normal  thyroid  or  its  enlargements 
are  subject  to  acute  inflammation  from  trauma  or  as  a  local  expression 


328 


THE  HEAD,  FACE,  AND  NECK 


of  systemic  infection,  such  as  that  incident  to  pyemia,  typhoid,  articular 
rheumatism,  persistent  constipation,  etc.  The  diagnosis  is  easily  made 
by  the  rapid  inflammatory  swelling  of  the  gland  associated  with  signs 
of  pressure,  particularly  venous  congestion  of  the  face,  and  dyspnea. 
It  may  undergo  resolution,  but  more  commonly  suppurates  and  is  not 
infrequently  attended  with  tissue  necrosis.  Abscess  may  open  externally 
or  burrow  deep.  Its  presence  will  be  indicated  either  by  fluctuation 
and  surface  redness,  or  by  well-marked  and  progressive  systemic  symp- 
toms of  pyogenic  infection. 

The  inflammation  exceptionally  assumes  a  chronic  type,  resulting 
in  an  induration  with  adhesions  to  surrounding  parts,  quite  impossible 
to  distinguish  from  cancer,  except  on  microscopic  examination. 


Fig.   120 


Parenchyraatous  goitre. 


Duration,  months.     Subjective  sjTnptoms,  heart  hurry,  insomnia, 
and  neurasthenia. 


Goitre. — Goitre  is  usually  an  acquired  affection;  occurring  congenitally 
and  associated  with  cretinism  where  the  disease  is  endemic. 

It  affects  mostly  women,  is  distinctly  hereditary,  is  predisposed  to  by 
congestion,  hence  often  develops  during  or  after  pregnancy,  especially 


THE  THYROID  329 

when  this  condition  is  rapidly  recurrent,  and  in  its  endemic  form  is 
supposed  to  be  due  to  drinking  water  contaminated  with  the  maritime 
deposits  of  the  "paleozoic  and  triassic  period  and  the  tertiary  age" 
(v.  Eiselsberg).  It  may  progressively  increase  in  size  until  it  has  reached 
huge  proportions,  may  attain  a  moderate  size  and  remain  stationary,  or 
may  even  retrograde.  The  increase  in  size  may  be  due  to  glandular 
proliferation,  hypersecretion,  or  vascular  or  connective-tissue  over- 
growth, commonly  to  an  association  of  all  these  conditions.  Thus  are 
formed  parenchymatous  or  adenoid,  colloid  (increased  secretion), 
fibroid,  cystic,  and  pulsating  goitres.  The  growth  may  appear  as  a 
diffuse  h}^ertrophy,  the  entire  gland  being  enlarged,  or  in  a  lobular 
form. 

The  Distinguishing  Characteristic  of  Goitre. — ^A  painless,  slowly  growing 
(years),  freely  movable  tumor,  occupying  the  position  of  the  thyroid, 
attached  to  the  larynx  and  moving  with  it,  lobular,  doughy  (colloid), 
fluctuating,  or  giving  pulsation  thrill  and  bruit.  Involvement  of  the 
accessory  thyroids,  if  these  be  unattached  and  the  thyroid  itself  be 
healthy,  might  be  suggested  by  the  position  of  the  tumor  at  the  base  of 
the  tongue,  behind  the  sternum  or  clavicle,  or  behind  the  pharynx  or 
esophagus.     The  administration  of  iodothyroid  might  be  helpful. 

In  the  newly  born  teratoma  may  move  with  the  larynx  and  correspond 
in  position  with  an  enlarged  thyroid.  Even  in  benign  goitre  of  moderate 
size  there  is  usually  sufficient  venous  congestion  to  cause  visible  enlarge- 
ment of  superficial  veins. 

A  highly  characteristic  symptom  is  dyspnea  and  noisy  breathing  on 
slight  exertion  incident  to  the  sudden  swelling  due  to  increased  blood 
tension.  Sudden  attacks  of  severe  dyspnea  and  acute  swelling  of  the 
goitre  are  characteristic  of  hemorrhages  into  its  substance. 

Alterations  in  the  voice,  spasms  of  coughing  incident  to  involvement 
of  the  recurrent  laryngeal  nerve  and  dysphagia  suggest  malignant  infil- 
tration, especially  if  the  symptoms  be  rapid  in  progression.  Dyspnea 
is  rarely  dependent  upon  recurrent  palsy,  since  this  must  be  bilateral 
to  cause  inspiratory  closure  of  the  larynx. 

Toxic  symptoms  are  always  present.  Insomnia,  headache,  neuras- 
thenia are  commonly  associated  with  rapid  heart  action.  The  fibroid 
and  cystic  forms  with  destruction  of  secreting  cells  and  absence  of  col- 
loid are  characterized  by  tetany  and  myxedema.  The  hyperplastic 
glandular  form  with  overvascularization  by  the  typical  symptoms  of 
Graves'  disease. 

Malignant  Infiltration. — Malignant  infiltration  usually  develops  in  glands 
already  enlarged  by  goitre.  Induration,  pain,  alteration  in  the  voice, 
dyspnea,  dysphagia,  and  cough  with  bloody  expectoration  are  character- 
istic of  malignancy.  Sarcoma  and  carcinoma  are  about  equally  common; 
both  exhibit  infiltrating  tendency  and  are  rapid  in  growth,  become 
shortly  fixed,  and  are  prone  to  metastases  in  the  lungs  and  bones,  particu- 
larly the  sterniun,  ribs,  and  skull. 

Sarcoma. — Sarcoma,  found  in  the  thyroid  in  every  known  variety, 
attacks  young  people  and  in  the  beginning  exactly  resembles  parenchy- 


330  THE  HEAD,  FACE,  AND  NECK 

matous  growth  of  one  lobe.  It  may  from  the  first  infiltrate  the  entire 
gland.  Its  rapid  and  progressive  increase  in  size  is  commonly  unilateral. 
Infiltration,  fixation,  and  prompt  development  of  pressure  symptoms 
(dyspnea,  dysphagia,  loss  of  voice,  bloody  expectoration)  establish  the 
diagnosis  when  it  is  no  longer  helpful  to  the  patient.  During  the  opera- 
tive stage,  i.  e.,  before  infiltration  and  metastases,  the  diagnosis  is  possible 
only  by  excision  and  examination. 


Fig.  121 

i 

i 

1 

^ 

1^^ 

"^ 

Carcinoma  of  thyroid.     Nodular,  fixed,  dense,  indurated,  and  of  rapid  growth  (months). 
(C.  H.  Frazier,  service  of  A.  C.  Wood.) 

Caxcinoma. — Carcinoma  customarily  begins  in  one  lobe,  though 
exceptionally,  as  in  sarcoma,  it  may  attack  primarily  the  entire  gland. 
The  growth  is  characterized  by  rapidity,  infiltration,  and  the  prompt  and 
progressive  development  of  pressure  symptoms.  At  times  the  micro- 
scope fails  to  detect  malignancy,  this  being  shown  only  by  metastases. 
Even  the  metastases  may  appear  benign  on  section,  and  from  their 
clinical  course  may  functionate  as  a  normal  gland,  since  at  least  in  one 
such  case  cachexia  developed  after  a  sternal  metastatic  carcinomatous 
growth  was  secondarily  removed  (v.  Eiselsberg).  Metastasis  may  occur 
when  the  original  growth  is  very  small. 


THE  THYMUS  GLAND  331 

Scirrhus. — Scirrhus  (rare),  often  of  small  size,  is  extremely  dense,  and 
by  infiltration  causes  early  pressure  symptoms  and  enlargement  of 
lymphatic  glands. 

Malignant  infiltration  of  a  benign  goitre  is  characterized  by  rapid 
growth,  increased  hardness,  pressure  symptoms,  and  lymphatic  enlarge- 
ments. 

Echinococcus  of  the  Thyroid. — Echinococcus  of  the  thyroid  (rare)  cannot 
be  distinguished  from  cystic  goitre  except  that  adhesions  to  surrounding 
tissues  are  more  marked  and  dyspnea  develops  early.  It  exhibits  a 
tendency  to  discharge  into  the  trachea. 


THE  THYMUS  GLAND. 

The  thymus  gland,  supposed  to  disappear  at  puberty,  sometimes  per- 
sisting through  life,  lies  close  to  the  trachea  in  the  anterior  mediastinum 
and  front  of  the  neck,  in  infants  extending  from  the  base  of  the  peri- 
cardium to  the  thyroid  gland.     Its  function  is  unknown. 

There  are  a  number  of  cases  of  thymus  death,  by  which  is  meant 
a  sudden  death  from  inadequate  cause,  often  preceded  and  always 
attended  by  venous  engorgement  and  at  times  by  tracheal  stridor, 
occurring  in  children  apparently  in  vigorous  health.  These  cases  of 
death  are  apparently  incident  to  pressure  upon  the  bloodvessels  of  the 
neck  and  secondarily  the  trachea  due  to  the  sudden  engorgement  of  the 
thymus  gland.  The  theory  of  spasm  due  to  nerve  pressure  cannot  be 
excluded.  In  children  thus  afflicted  there  is  usually  the  condition  known 
as  status  lymphaticus,  the  enlarged  thymus  is  associated,  as  a  rule,  with 
general  lymphatic  enlargement  and  a  flaccid  physique.  There  have 
been  reported  some  cases  of  chronic  dyspnea  in  early  life  associated 
with  marked  venous  engorgement  and  demonstrable  enlargement  of 
the  thymus  gland  For  the  relief  of  this  dyspnea  the  thymus  has  been 
removed  without  subsequent  changes  in  the  growth  or  nutrition. 

Sarcoma  of  the  thymus  has  been  observed  as  a  cause  of  mediastinal 
tumor,  the  true  nature  of  which  could  not  be  detected  by  any  clinical 
sign. 


CHAPTEE    XIII. 

THE  SPINAL  COLUMN. 

The  spinal  column  is  made  up  of  a  number  of  closely  articulated  bones 
firmly  bound  together,  but  flexible,  allowing  a  considerable  range  of 
motion,  as  a  whole,  in  the  direction  of  anteroposterior  and  lateral  flexion 
and  rotation.  The  position  of  the  spinous  processes  is  marked  by  a 
median  dorsal  groove,  in  which  the  examining  finger,  passing  from  the 
occiput  downward,  first  detects  the  spinous  process  of  the  sixth  cervical 
vertebra;  next  below  this,  but  not  always  more  prominent,  lies  the  seventh; 
the  first  thoracic  spine  may  be  more  prominent  than  either  of  these. 

The  spinous  process  of  the  third  thoracic  vertebra  is  marked  by  the  mid- 
point of  a  line  connecting  the  two  scapular  spines,  the  arms  hanging 
to  the  sides;  of  the  seventh  dorsal  vertebra  by  th^  midpoint  of  a  line 
drawn  across  the  back  between  the  inferior  angles  of  the  scapulae,  while 
a  line  similarly  drawn  between  the  highest  points  of  the  iliac  crests  marks 
the  position  of  the  fourth  lumbar  spine. 

The  cord  terminates  in  the  adult  at  the  lower  border  of  the  first  lumbar 
vertebra,  the  dorsal  sac  continuing  as  far  as  the  third  sacral  vertebra 
lying  just  below  a  line  joining  the  posterior  superior  iliac  spines. 

At  birth  the  spine  has  but  two  curves,  the  thoracic  and  the  sacral,  both 
concave  forward  and  but  slightly  marked.  The  two  secondary  curves 
that  develop  later  are  convex  forward  and  placed  in  the  cervical  and 
lumbar  portions  of  the  spine.  There  is  in  addition  a  slight  lateral  dorsal 
curve  convex  to  the  right. 

The  atlas  and  the  axis  depart  from  type,  since  they  are  intimately 
associated  with  the  movements  of  the  head  upon  the  spinal  column. 
The  former  bone  has  no  body  or  spinous  process.  The  latter  in  place 
of  a  body  has  a  tooth-like  process  projecting  upward  upon  which  the 
atlas  is  pivoted. 

The  spinal  canal  containing  the  cord  and  its  membranes  is  wide  in 
the  cervical  and  lumbar  regions  where  motion  is  free  and  the  cord  large, 
and  is  narrow  in  the  thoracic  region.  Between  the  inner  bony  wall  of  the 
canal  and  the  dura  is  the  epidural  space,  containing  bloodvessels  and 
cellular  tissue.  The  dura  forms  a  closed  sac  from  the  foramen  magnum 
to  the  coccyx,  sending  a  fibrous  investment  with  each  nerve  root  leaving 
the  cord.  The  dura,  because  of  its  great  strength  and  loose  attachment, 
may  remain  apparently  uninjured,  though  the  cord  be  crushed  by  fracture 
or  dislocation. 

The  transverse  process  of  the  atlas  can  be  felt  slightly  below  and  in 
front  of  the  tip  of  the  mastoid  process.  By  palpation  of  the  posterior 
pharyngeal  wall  can  be  felt  the  anterior  tubercle  of  the  atlas,  or,  if  the 
head  be  rotated,  its  arch  and  the  anterior  surfaces  of  the  bodies  of  the  axis 
and  the  third  cervical  vertebra. 


SYMPTOMATOLOGY  OF  AFFECTIONS  OF  THE  SPINAL  COLUMN     333 

General  Symptomatology  of  Affections  of  the  Spinal  Column. — 

Surgical  affections  of  the  spine  are  characterized  by  pain,  tenderness, 
deformity,  limitation  of  motion  or  fixation,  and  interference  with  the 
function  and  nutrition  of  the  parts  supplied  by  the  nerves  lying  within 
or  passing  through  the  spinal  canal. 

Fig.  122 


7th  cervical  vertebra  (vertebra  prominens). 


Outer  end  of  clavicle. 
Acromion  process. 

Root  of  spine  of  scapula  opp.  3d  dorsal  spine. 
Deltoid  muscle  and  bead  of  humerus  beneath. 


Teres  major  m. 

Thin  area  for  auscultation  and  puncture. 
Latissimus  dorsi  m. 
Angle  of  scapula. 


Spinal  furrow. 
Erector  spinje  muscles. 
Position  of  kidney. 
Crest  of  iJium, 


Top  of  sacrum. 

Posterior  superior  spine,  sacro-iliac  joint  just 

posterior. 
Greater  trochanter  of  femur. 


Surface  markings  of  the  back.      (G.  G,  Davis.) 

The  pain  may  be  located  at  the  site  of  injury,  infiltration,  or  inflamma- 
tion, or  may  radiate  along  the  course  of  those  nerves  the  roots  of  which 
are  involved.  It  is  usually  aggravated  by  motion,  and  it  may  exhibit  any 
grade  of  severity. 

The  tenderness  may  be  elicited  by  direct  palpation,  by  jarring  the 
whole  spinal  column,  or  by  motion. 


334  THE  SPINAL  COLUMN 

Tumor,  because  of  the  deep  position  of  the  spine,  is  rarely  detected  in 
its  early  stages  except  in  the  case  of  meningoceles  and  myeloceles.  De- 
formity is  a  valuable  immediate  symptom  after  fracture  and  luxation, 
a  late  one  in  infiltration  or  inflammations. 

Limitation  of  motion  is  one  of  the  earliest  symptoms  of  all  inflammatory 
affections,  and  is  most  marked  in  the  region  involved.  Fixation,  with 
demonstrable  muscular  atrophy,  is  a  late  development. 

The  symptoms  significant  of  root  or  cord  trauma  or  inflammation  are 
pain  referred  along  the  course  of  the  nerves  involved,  muscular  contrac- 
tion, paresis  or  paralysis,  hyperesthesia  or  tactile,  thermic  or  total  anes- 
thesia, exaggeration  or  abolition  of  spinal  reflexes,  and  trophic  changes 
which  in  complete  transverse  lesions  of  the  cord  may  be  rapid  in  devel- 
opment. 

Anomalies  of  the  Spinal  Column. — Spina  Bifida. — Spina  bifida 
incident  to  incomplete  development  of  the  lamina  of  one  or  all  the  verte- 
brae, produces  a  hernia-like  protrusion,  usually  in  the  lumbar  region, 
and  often  with  a  portion  of  the  cord  closely  attached.  AVhen  protrusion 
is  of  the  pia  arachnoid  alone,  it  is  called  meningocele;  when  the  cord  and 
its  nerves  are  contained  in  the  sac,  myelomeningocele;  when  the  bulging 
is  due  to  distention  of  the  central  canal  of  the  cord,  myelocystocele. 
Even  though  the  laminae  have  not  united,  there  may  be  no  bulging,  in 
which  case  the  condition  is  called  spina  bifida  occulta. 

Meningocele  has  usually  but  a  single  cavity.  It  escapes  through  a 
cleft  usually  narrow  and  to  one  side  of  the  midline.  There  may  be  no 
symptoms  other  than  the  presence  of  a  tumor,  often  covered  with  scar-like 
skin,  which  gives  a  sense  of  fluctuation  and  becomes  tense  when  the 
child  cries. 

The  meningomyelocele  usually  exhibits  a  broad  base.  Within  its  sac 
septa  can  sometimes  be  felt. 

Spina  bifida  occulta  may  be  characterized  by  no  symptoms  other  than 
excessive  growth  of  hair  over  the  defect. 

All  these  tumor  formations  are  likely  to  be  overlaid  by  a  fatty  heman- 
giomatous  or  lymphangiomatous  growth  in  the  subcutaneous  tissue. 
There  are  often  associated  deformities,  such  as  club  foot,  epispadia, 
hypospadia,  and  those  incident  to  paralysis. 

The  diagnosis,  usually  obvious,  may  be  difiicult.  The  distinction 
between  meningocele  and  myelocele  may  be  impossible  before  operation. 

In  the  coccygeal  region  there  may  be  a  tail-like  extension  which  may 
contain  supernumerary  vertebrae,  may  be  made  up  of  soft  fibrous  tissue 
alone,  or  of  an  overgrowth  of  either  skin  or  hair.  The  latter  condition 
is  significant  of  a  cleft  in  the  sacral  canal. 

In  addition  to  the  teratomata,  myeloceles;  and  meningoceles,  in  the 
sacrolumbar  region  overlaid  by  lipoma,  hemangioma,  or  lymphangioma, 
pure  lipomata  and  lymphangiomata  are  observed.  Moreover,  these  forms 
of  tumor  are  found  on  the  anterior  surface  of  the  coccyx  and  sacrum. 

The  commonest  congenital  malformation  in  the  region  of  the  coccyx 
appears  as  a  midline  dimple  or  pit  incident  to  the  inturning  of  a  skin 
pouch,  thus  forming  a  dermoid  sac,  which  is  later  subject  to  inflammation 


CURVATURE  OF  THE  SPINE  335 

causing  a  suppurating  sinus,  usually  mistaken  for  fistula  and  distinuished 
from  the  latter  by  the  fact  that  it  does  not  communicate  with  the  rectum, 
and  particularly  by  the  presence  of  hair  in  its  walls  and  in  its  discharge. 

The  tumors  and  cysts  placed  on  the  anterior  surface  of  the  coccyx 
and  sacrum  lying  between  these  bones  and  the  rectum  exhibit  their 
presence  by  interference  with  the  function  of  defecation,  and  are  readily 
detected  by  digital  examination.  A  cyst  due  to  persistence  of  a  postanal 
gut  may  reach  a  size  so  large  as  to  be  detected  both  by  abdominal  palpa- 
tion and  by  inspection  of  the  perineum. 

Cervical  Rib. — Cervical  rib  may  be  unilateral,  or  bilateral.  It  is 
incident  to  a  bony  outgrowth  from  the  transverse  process  of  the  last 
cervical  vertebra.  Though  probably  congenital,  symptoms  may  not 
develop  until  about  the  period  of  puberty  or  thereafter.  These  are 
essentially  those  of  pressure.  They  are  manifested  by  pain,  neuritis, 
or  even  palsy  in  the  distribution  of  the  brachial  plexus,  and  exceptionally 
by  the  production  of  aneurysm.  The  affection  is  usually  not  recognized 
until  pressure  symptoms  become  pronounced.  It  is  detected  then  by 
palpation  and  certainly  by  the  a;-rays.  In  many  cases  the  condition  causes 
no  symptoms. 

Absence  of  vertebra  has  been  noted,  but  in  itself  occasions  no  symp- 
toms.    It  is  usually  associated  with  other  more  obvious  deformities. 

Curvature  of  the  Spine. — This  may  be  with  its  convexity  lateral  (scoliosis), 
posterior  (kyphosis),  anterior  (lordosis),  or  combined. 

Lateral  curvature,  exceptionally  congenital,  usually  beginning  between 
the  sixth  and  tenth  years,  and  exhibiting  no  sex  predilection,  is  usually 
due  to  an  habitual  faulty  posture,  or  unequal  length  of  the  lower  extrem- 
ities. Muscular  palsy,  thoracic  empyema,  rickets,  osteomalacia,  and 
affections  resulting  in  a  limp  are  also  common  causes.  The  primary 
curve  is  usually  left  convex  in  the  lumbar  regions,  with  dorsal  compensa- 
tion in  the  opposite  direction.  Or  there  may  be  a  single  lateral  bulge, 
called  total  scoliosis.  Associated  with  the  lateral  curve  there  is  rotation 
of  the  vertebrae  producing  asymmetry  of  the  chest. 

Diagnosis  is  based  upon  examination  with  the  patient  stripped  to 
the  top  of  the  trochanters.  This  affection  early  shows  inequality  in 
the  height  of  the  shoulders,  scapular  prominence,  elevation  of  one  hip, 
asymmetry  of  the  two  sides  of  the  chest,  and  often  deviation  of  the 
spinous  processes  from  the  dorsal  vertical  furrow.  The  normal  position 
of  the  spinous  processes  is  indicated  by  running  a  line  from  the  mid- 
occiput  to  the  gluteal  cleft.  There  may  be  considerable  rotation  without 
marked  departure  of  the  spinous  processes  from  this  position.  The 
dorsal  asymmetry  of  the  chest  is  accentuated  by  having  the  patient  with 
straight  knees  bend  forward,  attempting  to  touch  the  floor  with  the 
fingers. 

Limitation  of  motion  is  often  an  early  sign.  The  patient  is  directed  to 
flex  and  extend  the  trunk;  to  bend  it  first  to  one  side  and  then  to  the  other, 
to  rotate  the  shoulders  to  the  right  and  the  left  as  far  as  possible.  Limita- 
tion in  one  direction  is,  in  the  absence  of  other  cause,  suggestive  of 
beoinning  cun^ature. 


336  THE  SPINAL  COLUMN 

Kyphosis,  or  convex  posterior  curvature,  is  usually  postural  when  not 
incident  to  antecedent  disease,  such  as  tuberculosis  or  rickets.  It  is  a 
common  deformity  of  youth,  is  often  developed  by  occupations  requiring 
prolonged  stooping,  and  is  stated  by  specialists  to  be  caused  by  adenoids 
or  enlarged  tonsils.     The  deformity  is  obvious. 

Lordosis  is  a  condition  of  sway-back  which  is  usually  compensatory,  as 
in  case  of  bilateral  luxation  of  the  hip,  or  spondylolisthesis,  i.  e.,  forward 
and  downward  displacement  of  the  body  of  the  last  lumbar  vertebra. 
This  malposition  is  usually  symptomless,  excepting  for  undue  prominence 
of  the  sacriun  and  the  iliac  crests.  It  may  be  an  early  sign  of  Pott's 
disease. 

The  neurotic  spine  is  characterized  by  pain,  which  may  be  severe 
and  localized,  particularly  in  the  region  of  the  last  cervical  vertebra,  by 
extreme  sensitiveness  to  pressure,  limitation  of  motion,  and  general  invalid- 
ism. Often  there  may  be  an  associated  curve.  Diagnosis  is  made  only 
after  prolonged  observations  and  repeated  examinations  show  a  want  of 
consistency  in  the  symptoms  and  that  they  are  relieved  or  exaggerated 
by  causes  inadequate  to  so  affect  a  local  lesion  (see  p.  211). 

Trauma  of  the  Spine. — In  the  absence  of  fracture  or  luxation  the 
cord  is  so  well  protected  that  it  seems  scarcely  amenable  to  con- 
cussion. Clinically,  however,  cases  are  encountered  which,  following 
trauma,  exhibit  primary  shock  and  for  a  brief  period  the  symptoms 
of  a  complete  transverse  lesion  of  the  cord.  The  complete  and  rapid 
recovery  is  the  only  proof  of  the  absence  of  a  demonstrable  cord 
lesion. 

The  diagnosis  of  this  rare  condition  can  be  made  only  by  the  prompt 
convalescence  of  the  patient.  Injuries  and  diseases  of  the  cord  and 
roots  are  discussed  under  the  Nervous  System. 

Sprain  and  Contusion. — Sprains  and  contusions  of  the  spine  are  char- 
acterized by  pain  which  is  usually  severe,  is  aggravated  by  motion,  may 
give  root  radiations,  and  is  attended  with  a  protective  muscular  fixation 
and  tenderness,  usually  fairly  well  localized.  There  is  no  displacement, 
though  a  previously  existing  aberration  in  the  contour  of  the  spinous  pro- 
cesses may  lead  to  the  suspicion  that  such  is  of  recent  traumatic  origin. 

Absence  of  cord  symptoms,  the  transitory  nature  of  the  suffering  and 
disability,  and  the  relief  afforded  by  strapping,  support  and  massage 
are  indices  of  the  absence  of  a  more  serious  lesion.  The  symptoms  are, 
however,  precisely  those  of  fracture  without  displacement;  their  persist- 
ence and  their  aggravation  by  treatment  appropriate  to  sprain  should 
suggest  either  bone  lesion  or  the  onset  of  a  local  tuberculosis. 

Fractures  and  Dislocations  of  the  Spine. — ^These  injuries  are  usually 
combined,  though  either  may  exist  without  the  other.  They  are  com- 
monest in  vigorous,  active  men,  and  usually  involve  the  fourth,  fifth,  or 
sixth  cervical  and  the  last  two  thoracic  and  first  lumbar  vertebrse. 

In  fracture  the  bodies  of  the  vertebrse  are  the  parts  chiefly  involved, 
and  the  movement  producing  the  injury  is  generally  one  of  forced  flexion. 
The  force  applied  may  be  comparatively  slight  or  overwhelming.  The 
injury  may  involve  one  or  several  vertebrae. 


FRACTURES  AND  DISLOCATIONS  OF  THE  SPINE 


337 


The  deformity  if  present  is  usually  in  the  form  of  kyphosis  or  obvious 
backward  projection  of  the  spinous  processes.  In  the  three  upper  ver- 
tebrae forward  displacement  may  be  detected  by  examinations  through 
the  pharynx.  There  may  be  lateral  deviation.  There  is  always  local 
tenderness  elicited  by  direct  palpation,  percussion,  or  manipulation  of  the 
spinous  process  of  the  involved  vertebra;  even  slight  movement  of  the 
spine  is  painful.     Crepitus  may  be  felt,  but  should  not  be  searched  for. 


Fig.   123 


Fracture  of  the  cervical  spine  involving  the  bodies  of  the  sixth  and  seventh  vertebrse.  A 
momentary  displacement  of  one  of  these  bones,  probably  the  sixth,  with  immediate  replacement, 
evidently  accompanied  the  injury,  because  the  cord  was  severely  injured  though  not  severed, 
and  the  radiograph  shows  tlie  vertebrae  to  be  in  line.  Patient  a  young  adult.  Cause  of  the  injury 
was  hyperflexion  during  an  attempt  to  make  a  '  'tackle"  on  a  friend  during  play,  but  not  in  football 
practice  nor  in  a  game.  The  anteroposterior  view  in  this  case  shows  no  indication  of  the  fractures. 
The  lateral  view  is  always  the  best  for  determining  fractures  of  the  cervical  bodies,  but  it  is  seldom 
that  a  radiograph  can  be  made  to  include  as  low  down  as  the  seventh,  as  in  this  case,  and  often  it 
is  impossible  to  show  below  the  fifth  vertebra,  where  fractures  usually  occur. 


Cord  injury  is  expressed  by  motor,  sensory,  and  reflex  phenomena, 
which,  if  due  to  the  crushing  force  of  displaced  bone,  are  instantaneous 
in  development  and  more  or  less  permanent;  if  caused  by  hemorrhage, 
symptoms  develop  more  slowly  (minutes,  hours);  if  by  traumatic  reaction, 
still  more  slowly  (days,  weeks,  months). 

Complete  transverse  lesion,  usually  but  not  always  indicative  of  frac- 
ture dislocation,  is  characterized  by  flaccid  palsy  of  the  parts  supplied  by 
that  portion  of  the  cord  lying  below  the  seat  of  injury  and  by  complete 
absence  of  tendon  reflexes.  Death  is  immediate  from  asphyxia  when 
the  first  four  segments  of  the  cord  are  involved.  In  lesions  lower  down, 
above  the  line  of  anesthesia,  there  is  usually  a  zone  of  hyperesthesia 
incident  to  irritation  of  the  undestroyed  roots  and  cord  immediately 
adjacent.  Localizing  symptoms  are  given  in  the  section  devoted  to  the 
Nervous  System  (p.  190). 
22 


338 


THE  SPINAL  COLUMN 


Lesion  of  the  cord,  either  partial  or  completely  transverse,  has  been 
observed  in  the  absence  of  either  fracture  or  demonstrable  luxation,  this 
condition  being  accounted  for  by  a  luxation  which  was  immediately 
reduced. 

Dislocation  unaccompanied  by  fracture  is  noted  almost  solely  in  the 
cervical  region  involving  chiefly  the  fourth,  fifth,  and  sixth  cervical 
vertebrae.  The  dislocation  is  commonly  unilateral,  and  is  due  to  a  twist- 
ing force,  the  lower  articular  cartilage  of  the  displaced  vertebra  riding 
forward  over  the  cartilage  below  it  and  either  resting  upon  its  anterior 
border  or  dropping  into  the  depression  in  front.  This  necessarily  implies 
at  least  a  sprain  of  the  intervertebral  articulation  of  the  other  side. 


Fig.  124 


Fig.  125 


Left  subluxation  of  the  fifth  cervical  vertebra.     (Von  Bergmann.) 


The  condition  is  characterized  by  severe  pain  which  may  be  most 
marked  in  the  lateral  articulation  least  involved.  The  pain  is  greatly 
aggravated  by  motion,  particularly  such  as  tends  to  increase  the  char- 
acteristic rotation  and  lateral  flexion  of  the  head  toward  the  sound 
side.  Deviation  of  the  spinous  process  from  the  midline  can  sometimes 
be  felt.  Increased  prominence  of  the  body  of  the  vertebra  and  the 
lateral  process  on  the  dislocated  side  is  readily  palpable  through  the 
posterior  pharyngeal  wall  in  the  case  of  the  upper  vertebrae.  The 
findings  of  the  ic-rays  are  conclusive.  This  luxation  may  undergo 
spontaneous  reduction  during  etherization. 

When  the  luxation  is  complete  and  bilateral  there  will  be  an  anterior 
deformity  and  forward  projection  of  the  displaced  vertebra,  and  flexion 


FRACTURES  AND  DISLOCATIONS  OF  THE  SPINE  339 

at  the  seat  of  displacement,  though  this  may  be  concealed  by  compensa- 
ting extension  of  the  vertebrae  above. 

Partial  or  complete  dislocation  of  the  atlas  and  axis  are  reported 
incident  to  forced  flexion  or  rotation,  usually  attended  with  fracture, 
especially  of  the  odontoid,  and  commonly  resulting  in  immediate  death. 
Because  of  the  roomy  canal  in  this  portion  of  the  spine  the  cord  may  be 
but  slightly  or  not  at  all  pressed  upon.  The  head  fixed  in  flexion,  the 
deformity,  recognized  by  examination  of  the  pharyngeal  wall,  and  the 
results  of  an  .r-ray  examination  would  establish  the  diagnosis.  When 
such  injuries  are  suspected,  movements  of  the  head  for  diagnostic  pur- 
poses are  contra-indicated. 

Fracture  ■unaccompanied  by  dislocation  usually  of  the  vertebral  bodies 
exhibits  the  symptoms  of  severe  sprain  with  more  pronounced  and 
persistent  local  tenderness  best  elicited  by  percussion  or  manipulation 
of  the  spinous  process.  Deformity,  if  present,  appears  in  the  form  of  an 
unnatural  prominence  of  the  spinous  process  of  either  the  fractured  ver- 
tebra or  the  one  above  or  below  the  seat  of  fracture.  This  deformity 
immediately  after  the  injury  is  lessened  or  caused  to  disappear  on 
extension;  it  becomes  permanent  from  ankylosis  on  recovery.  The 
x-T&YS  may  be  diagnostic. 

Though  the  presence  or  absence  of  lesions  of  the  spinal  cord  is  of 
major  importance,  the  determination  as  to  whether  or  not  the  bone  has 
been  broken  by  violence  in  the  absence  of  such  lesion  is  essential,  since  a 
failure  to  recognize  fractures  of  the  bodies  of  the  vertebrae  or  of  the  inter- 
vertebral disks  without  displacement,  and  therefore  a  neglect  to  secure 
rest  sufficiently  prolonged  for  complete  healing,  is  probably  responsible 
for  post-traumatic  spondylitis  (see  p.  342). 

When  the  spinous  processes  are  fractured,  usually  from  direct  violence, 
preternatural  mobility  and  crepitus  may  be  elicited.  Fractures  of  the 
laminae  are  of  major  importance  only  if  they  be  complicated  by  external 
wound  or  cord  symptoms. 

Fracture  Dislocations.  Forced  flexion,  as  from  a  fall  backward  on  the 
head  and  neck,  is  prone  to  cause  a  forward  dislocation  of  the  fourth, 
fifth,  or  sixth  cervical  vertebra,  with  an  oblique  fracture  of  the  body  of 
the  vertebra  below  it,  the  plane  of  fracture  running  from  above  down- 
ward and  forward,  so  that  the  displaced  vertebra  carries  the  fragment 
forward  with  it.  This  is  the  type  of  dislocation  fracture  commonly 
observed  in  the  lower  cervical  and  upper  dorsal  regions,  and,  because 
of  the  wide  displacement  favored  by  the  fracture,  the  cord  is  generally 
involved. 

Impact  and  forced  flexion  in  the  dorsolumbar  region,  as  from  a  heavy 
fall  on  the  buttocks  or  feet  or  the  imposing  of  an  overw^helming  weight 
on  the  shoulders,  causes  a  crushing  fracture  of  the  bodies  of  one  or  more 
of  the  dorsolumbar  vertebrae,  particularly  the  eleventh,  twelfth,  and  first, 
which  may  or  may  not  be  complicated  by  dislocation.  In  the  former 
event  there  may  be  no  cord  symptoms,  or,  because  of  a  backward  displace- 
ment of  a  bone  fragment,  these  may  be  pronounced.  In  the  latter  case 
the  symptoms  are  usually  those  of  more  or  less  complete  transverse  lesion. 


340  THE  SPINAL  COLUMN 

The  diagnosis  of  fracture  dislocation  is  based  upon  the  undue  promi- 
nence of  the  spinous  processes,  with  or  without  lateral  deviation,  local 
tenderness,  pairl  both  local  and  radiating,  usually  total  disability,  and 
frequently  the  evidence  of  local  cord  lesion.  The  x-rays  may  be  abso- 
lutely diagnostic. 

Wounds  of  the  vertebrae  are  usually  detected  by  direct  examination. 
Gunshot  wounds  with  modern  weapons  are  of  particular  importance 
because  of  the  associated  cord  lesion,  which  may  be  completely  trans- 
verse even  though  the  bone  be  not  extensively  shattered. 

Inflammation  of  the  Spine. — Acute  Suppurative  Spondylitis.— Acute 
osteomyelitis  of  the  spine  is  an  affection  of  youth,  commonest  in  the 
lumbar  region,  and  most  likely  to  develop  in  the  bodies  of  the  vertebrae, 
though  it  may  involve  any  portion.  It  may  follow  either  slight  or  severe 
trauma;  the  source  of  infection  can  often  be  traced  to  a  preceding  boil, 
carbuncle,  sore  throat,  or  suppurating  area. 

It  is  characterized  by  the  constitutional  symptoms  of  pronounced 
sepsis,  being  usually  inaugurated  by  chill  and  high  fever.  There  is  local 
fixation  of  the  spine,  tenderness  to  palpation,  though  the  latter  may  not 
be  marked,  and  severe  pain  aggravated  by  motion  and  radiating  along 
the  course  of  the  nerves  the  roots  of  which  pass  close  to  the  infected 
area,  often  associated  with  muscular  spasm. 

In  the  cervical  region  torticollis  and  rigidity  develop  early,  and  are 
soon  followed  by  postpharyngeal  swelling,  which  makes  both  swallowing 
and  breathing  difficult. 

In  the  thoracic  region  a  secondary  pleural  effusion  is  quickly  formed 
and  usually  obscures  the  diagnosis.  Rigid  belly  walls  and  extreme  pain 
may  also  suggest  peritonitis. 

Diagnosis  is  based  upon  the  violent  onset  of  the  septic  symptoms,  their 
persistence  and  aggravation,  the  localized  tenderness  and  fixation  of  the 
spine,  and  the  elimination  of  other  causes  for  the  condition,  such  as  mas- 
toiditis, or  meningitis.  The  pleural  effusion  secondary  to  involvement 
of  the  thoracic  vertebra,  at  first  purely  serous,  later  becomes  purulent. 
A  pleurisy  has  neither  the  stormy  onset,  the  vertebral  fixation  and  ten- 
derness, the  pain  radiations  and  muscular  spasm,  nor  the  progression 
of  symptoms  after  tapping.  When  the  vertebral  bodies  are  involved 
in  an  acute  osteomyelitis,  the  prognosis,  grave  at  the  best,  is  almost 
absolutely  bad  in  the  absence  of  early  intervention,  death  being  from 
sepsis  or  meningitis. 

Tuberculous  Spondylitis. — ^Tuberculosis  of  the  spine  attacks  by  prefer- 
ence male  children  before  puberty,  being  most  frequent  before  the  fifth 
year,  though  it  may  develop  at  any  period  of  life.  The  seats  of  prefer- 
ence are  the  anterior  portions  of  the  bodies  of  the  lower  thoracic  and 
upper  lumbar  vertebrae  and  their  intervertebral  cartilages.  It  may 
involve  simultaneously  more  than  one  portion  of  the  spine.  From  dis- 
integration of  the  anterior  vertebral  bodies  and  their  cartilages  angulation 
results,  forming  kyphosis,  which,  when  several  vertebrae  are  involved,  may 
appear  as  a  rounded  bulging.  Abscess  usually  forms  and  may  reach 
huge  size. 


TUBERCULOUS  SPONDYLITIS  341 

Of  the  upper  cervical  vertebrae,  the  axis^is  the  one  most  frequently 
affected,  the  resulting  abscess,  if  one  develops,  appearing  behind  the 
pharynx  and  producing  difficulty  in  swallowing  and  breathing.  It  may 
burrow  downward  into  the  posterior  mediastinum,  or  open  to  the  inner 
or  outer  side  of  the  lower  attachment  of  the  sternomastoid  musclC;  or 
even  present  at  the  arm  pit. 

The  abscess  of  dorsal  caries  exceptionally  presents  along  the  com-se  of 
the  ribs.  It  is  more  prone  to  follow  the  course  of  the  great  vessels,  pre- 
senting in  the  groin,  exceptionally,  on  the  buttock.  The  abscess  of  dorso- 
lumbar  origin  follows  the  course  of  the  psoas  muscle,  presenting  beneath 
Poupart's  ligament  on  the  outer  side  of  the  bloodvessels  or  burrowing  still 
lower  in  the  leg.  When  the  arches  are  involved  in  the  tuberculous  pro- 
cess the  abscess  customarily  points  backward.  In|its  ultimate  development 
caries  not  infrequently  involves  the  cord  and  its  nerves,  producing  in- 
flammatory and  pressure  symptoms,  exceptionally  incident  to  narrowing 
of  the  bony  canal,  usually  due  to  pachymeningitis. 

Tuberculous  spondylitis,  obvious  in  its  later  course,  is  characterized 
in  its  early  stages  by  pain,  which  may  be  persistent  and  of  a  throbbing 
character  and  exhibit  severe  exacerbations  with  radiations  incident  to  jars 
or  sudden  motion,  by  rigidity  of  the  affected  part  of  the  spine,  and  by  the 
habitual  assumption  of  such  postures  as  tend  to  remove  the  weight  of  the 
body  from  the  diseased  area.  Moreover,  there  are  often  night  cries  due 
to  sudden  spasmodic  contraction,  torticollis  when  the  disease  involves 
the  upper  cervical  vertebrae,  shallow,  grunting  respiration  and  irritative 
cough  when  the  dorsal  vertebrae  are  affected,  and  colicky  pains  in  dorsal 
and  dorsolumbar  involvement.  Particularly  in  the  case  of  children  there 
is  a  marked  change  in  habits  and  disposition,  cheerful  activity  being 
replaced  by  a  condition  of  languor  and  querulousness.  There  is  steady 
deterioration  in  general  health,  and  the  tuberculin  reaction  is  positive. 

The  diagnosis  is  strongly  suggested  by  local  tenderness  and  fixation 
of  a  child's  spine  after  slight  trauma,  or  in  the  absence  of  this,  these 
symptoms  persisting  and  growing  worse.  In  the  case  of  infants  it  is 
often  not  suspected  imtil  distinct  deformity  occurs,  the  general  irritability, 
failure  in  health,  crying  on  being  lifted  or  moved,  and  tendency  to  keep 
the  spine  rigid  being  attributed  to  colic  or  any  of  a  number  of  various 
causes. 

The  examination  for  suspected  tuberculous  spondylitis  is  conducted  by 
stripping  the  patient  to  the  trochanters,  or  below.  Standing  with  heels 
together,  knees  straight,  and  pelvis  held  by  the  examiner,  the  patient 
is  directed  to  bend  forward  as  far  as  possible;  this  motion  will  accentuate 
a  beginning  prominence  of  the  spinous  processes,  will  be  limited,  and 
will  occasion  pain. 

With  the  body  straight  and  the  pelvis  still  held,  the  patient  is  directed 
to  look  as  far  back  as  possible,  first  over  one  shoulder,  then  over  the 
other.  This  motion  will  be  limited  usually  in  both  directions;  the 
approximate  region  of  limitation  may  be  further  determined  by  fixing 
the  shoulders  and  directing  similar  motion  to  be  made  with  the  head. 

The  patient  is  told  to  pick  a  small  object,  such  as  a  match,  from  the 


342  THE  SPINAL  COLUMN 

floor;  the  stooping  is  done  at  the  thigh,  knee,  and  ankle,  the  back  being 
kept  straight,  and  on  rising  there  is  a  tendency  to  use  the  hands  on  the 
thighs  as  a  help. 

The  patient  is  placed  in  ventral  decubitus,  and,  with  the  pelvis  held 
down,  the  straight  leg  is  lifted  upward,  this  to  test  contraction  of  the 
psoas  muscle.  Along  the  line  of  the  spinous  processes  light  percussion 
is  practised  to  elicit  local  tenderness. 

When  the  cases  of  tuberculous  spondylitis  present  themselves  for 
examination  there  is  usually  kyphosis  and  unmistakable  spinal  rigidity 
and  tenderness,  making  the  diagnosis  obvious.  In  the  early  stages  the 
symptoms  which  are  most  characteristic,  and  which  may  not  be  elicited 
without  careful  examination,  are  limitation  of  motion  in  the  spine  and 
slight  tenderness  on  local  manipulation  and  percussion.  Torticollis, 
thigh  flexion  from  psoas  involvement,  and  referred  pain  may  be  early 
symptoms. 

In  some  cases  of  tuberculous  spondylitis  the  onset  is  insidious,  even 
the  general  health  remaining  apparently  unaffected,  and  angular  deformity 
is  the  first  symptom  which  calls  for  an  examination. 

To  distinguish  tuberculous  spondylitis  from  chronic  post-traumatic, 
or  from  syphilitic  spondylitis,  may  in  the  beginning  be  quite  impossible, 
except  by  means  of  a  negative  tuberculin  test.  The  age  incidence  is 
helpful,  since  the  tuberculous  process  is  rare  in  the  adult  and  frequent 
in  little  children.  The  reverse  is  the  case  in  regard  to  the  two  other 
affections. 

Typhoid  Spondylitis. — Typhoid  spondylitis  occurs  late  in  the  course  of 
typhoid  fever,  or  even  after  convalescence  seems  fully  established.  It  is 
marked  by  the  sudden  onset,  in  the  lower  dorsal  or  lumbar  region,  of 
severe  pain,  both  local  and  referred,  aggravated  beyond  endurance  by 
the  slightest  movement^  associated  at  times  with  muscular  spasm.  Con- 
stitutional symptoms  are  slight  or  wanting.  Paresis  of  the  bladder  and 
rectum  have  been  noted. 

The  diagnosis  is  based  on  the  sudden  or  rapid  development  and  per- 
sistence (weeks,  months)  of  pain  and  rigidity  following  typhoid  fever. 

Gonorrheal  Spondylitis. — Gonorrheal  spondylitis,  a  rare  complication 
of  gonococcal  infection,  in  its  symptomatology  closely  simulates  typhoid 
spine.  The  diagnosis  is  based  upon  the  presence  of  gonococcal  infection, 
the  sudden  onset  of  pain,  tenderness  and  fixation  in  the  spine  area,  and 
the  betterment  which  promptly  follows  the  removal  of  an  infecting  focus. 

Chronic  Traumatic  Spondylitis. — ^This  is  an  inflammatory  condition  which 
may  be  immediately  sequent  to  spinal  injury  or  may  follow  it  by  an 
interval  of  weeks  or  months.  It  is  characterized  by  localized  pain  and 
tenderness  about  the  seat  of  injury,  the  former  greatly  aggravated  by 
motion  often  referred  and  crippling  in  intensity,  by  both  voluntary  and 
involuntary  fixation  of  the  back  by  muscular  action,  by  the  gradual 
(months)  development  of  deformity,  usually  kyphosis,  and  by  apparently 
causeless  exacerbations  or  remissions.  There  is  a  softening  process 
incident  to  inflammation,  in  turn  probably  kept  up  by  inadequate  treat- 
ment of  an  unsuspected  fracture. 


TUMORS  OF  THE  VERTEBRAE  343 

The  distinction  from  early  tuberculosis  is  in  children  impossible 
except  there  be  obtained  a  negative  tuberculin  test.  The  early  severe 
crippling  pain  in  adults,  who  are  less  subject  than  children  to  Pott's 
disease,  would  suggest  an  osteitis  of  other  than  tuberculous  origin.  The 
absolute  diagnosis  even  in  them  must  be  a  matter  of  time,  observation, 
and  the  results  of  the  tuberculin  test. 

Spondylitis  Deformans. — Spondylitis  deformans,  or  osteitis  deformans, 
called  also  rheumatoid  arthritis,  is  usually  one  of  the  local  manifestations 
of  a  general  trouble.  It  may,  however,  be  confined  entirely  to  the  spine, 
and  may  begin  in  childhood.  The  affection  is  characterized  by  pain, 
tenderness,  and  gradual  stiffening,  requiring  for  its  full  development  many 
years.  The  normal  curvatures  undergo  gradual  modification,  and  the 
spine  exhibits  but  a  single  dorsal  curve.  The  pain  is  subject  to  remis- 
sions. Root  pressure  may  occasion  severe  referred  paroxysms  or  may 
cause  sensory  or  motor  palsy. 

This  affection  not  infrequently  begins  in  the  neck,  travelling  down- 
ward. The  recognition  of  the  well-developed  disease  offers  no  difficulty. 
In  its  incipiency,  especially  when  it  begins  in  childhood,  the  distinction 
from  tuberculous  spondylitis  is  difficult,  and  will  in  the  main  depend 
upon  the  results  of  the  tuberculin  test  and  prolonged  observation. 

Syphilis. — Syphilis  of  the  bodies  of  the  vertebrae  (rare)  may  appear  in 
either  the  hereditary  or  acquired  form  of  the  disease.  It  may  so  closely 
simulate  tuberculosis  in  its  early  development  as  to  make  a  diagnosis 
impossible,  excepting  it  be  based  upon  a  history  of  syphilis  and  associated 
evidence  of  this  and  the  negative  evidence  of  the  tuberculin  test. 

Actinomycosis. — Actinomycosis  (rare)  cannot  be  diagnosticated  as  such 
except  by  the  finding  of  the  ray  fungus  in  the  discharge  and  associated 
lesions  elsewhere. 

Tumors  of  the  Vertebrae. — ^Tumors  of  the  vertebra?  are  nearly 
always  malignant  and  secondary.  Carcinoma  is  the  usual  form  and  is 
frequently  sequent  to  primary  foci  in  the  breast,  uterus,  or  prostate.  In 
metastasis  from  the  prostate  the  spinal  manifestations  may  precede 
the  appearance  of  clinical  signs  indicating  the  original  focus  of  infiltra- 
tion. As  a  rule,  the  body  of  but  one  vertebra  is  involved;  this  is 
commonly  in  the  lower  thoracic  or  lumbar  region. 

Primary  sarcoma  is  more  frequently  reported  than  primary  carcinoma. 

Myeloma,  extremely  rare,  characterized  by  a  softening  of  the  bone, 
resembles  osteomalacia  rather  than  tumor,  from  which  it  is  distinguished 
by  the  failure  of  medicinal  and  hygienic  therapeutics  to  accomplish 
betterment. 

Exostoses  and  cartilaginous  overgrowths  (rare)  produce  only  pressure 
symptoms.  They  may  mechanically  interfere  with  motion.  They  are 
usually  associated  with  similar  outgrowths  from  other  and  more  accessible 
bones. 

The  diagnosis  of  tumor  of  the  vertebra  is  based  upon  pressure  symp- 
toms, at  least  in  the  early  stage  of  the  development  of  these  growths. 
These  are  manifested  in  the  form  of  pain  located  at  the  seat  of  infiltra- 
tion, radiating  along  the  course  of  the  involved  nerves,  and  in  the  case  of 


344  THE  SPINAL  COLUMN 

malignant  growths  becoming  rapidly  excruciating  in  type.  The  involved 
area  is  usually  sensitive  to  deep  palpation;  ultimately  deformity  and  at 
times  tumor  develop.  Deformity  in  case  of  malignant  growths  is  usually 
sudden  and  incident  to  slight  trauma. 

In  distinguishing  from  tuberculous  infiltration,  the  age  incidence,  the 
steady  progression  of  the  affection,  the  failure  of  extension  to  relieve 
the  pain,  the  evidences  of  both  cord  and  root  pressure,  and  particularly 
the  discovery  of  a  primary  focus  are  of  importance.  Moreover,  a  tuber- 
culin test  is  likely  to  be  helpful. 

An  eroding  aortic  aneurysm  will  cause  much  the  same  symptoms  as  a 
cancerous  infiltration,  but  is  usually  distinguished  by  other  characteristic 
symptoms  of  this  condition. 

The  detection  of  benign  tumors  depends  entirely  upon  their  slow 
development  and  the  persistence  of  symptoms  of  localized  root  or  cord 
pressure  or  both.  Pain  is  likely  to  be  the  dominant  feature.  AVhen  the 
growth  is  a  bony  one,  the  ar-rays  will  be  helpful. 


CHAPTER    XIA^ 

THE  UPPER  EXTREMITY. 
THE  HAND  AND  WRIST. 

The  skin  on  the  dorsum  of  the  hand  is  comparatively  thin,  loosely 
attached,  and  there  can  be  seen  coursing  beneath  it  a  number  of  large 
veins.  The  palmar  skin  is  thick,  richly  supplied  with  sweat  glands,  and 
closely  attached  to  the  deeper  tissues  by  an  abundance  of  connective- 
tissue  bands  running  vertically  downward.  The  sheaths  of  the  flexor 
tendons  extend  from  the  base  of  the  third  phalanx  to  the  level  of  the  meta- 
carpophalangeal joints,  with  the  exception  of  the  flexor  sheath  of  the 
little  finger,  which  usually  communicates  directly  with  the  common  flexor 
bursa  lying  beneath  and  above  the  annular  ligament.  The  sheath  of 
the  flexor  longus  pollicis  also  passes  directly  beneath  the  annular  liga- 
ment and  into  the  forearm. 

The  knuckles  of  the  closed  fist  are  formed  by  the  distal  end  of  the 
metacarpals  and  the  first  row  of  the  phalanges. 

On  the  palmar  surface  of  the  wrist  to  the  radial  side,  and  at  a  lower 
level  than  the  styloid  process,  may  be  felt  the  tuberosity  of  the  scaphoid, 
and  immediately  below  this  the  ridge  of  the  trapezium.  To  the  ulnar 
side  and  about  the  same  level  may  be  felt  the  pisiform  with  the  unciform 
more  deeply  placed  and  internal  to  it.  The  interphalangeal  joints  allow 
of  flexion  and  extension.  The  metacarpophalangeal  joints  also  of 
abduction  and  adduction  when  the  fingers  are  extended. 

The  radial  and  ulnar  styloid  processes  are  the  prominent  bony  points 
about  the  wrist.  A  line  joining  the  tips  of  the  styloid  processes  does  not 
form  a  right  angle  to  the  long  axis  of  the  forearm,  the  radial  process 
lying  at  a  lower  level  (quarter  to  half  an  inch). 

The  bony  projection  just  proximal  to  the  base  of  the  third  metacarpal 
bone,  made  prominent  by  flexion  of  the  wrist,  is  the  os  magnum. 

To  the  outer  side  of  the  wrist  in  the  depression  bounded  on  the  radial 
side  by  the  tendons  of  the  extensor  ossis  metacarpi  pollicis,  and  extensor 
brevis  pollicis,  on  the  inner  (ulnar)  side  by  the  extensor  longus  pollicis,  lies 
the  snuff  box,  a  skin  hollow  made  conspicuous  by  abduction  and  exten- 
sion of  the  thumb. 

In  its  depth  the  trapezium  can  be  palpated. 

Though  the  metacarpals  and  phalanges  are  easily  palpated,  fractures 
of  these  bones  may  escape  detection. 

The  wrist  joint  allows  of  flexion  until  the  long  axis  of  the  hand  makes 
a  right  angle  with  that  of  the  forearm,  extension  to  a  little  more  than 


348 


THE  UPPER  EXTREMITY 


half  this  degree,  abduction  (to  the  radial  side)  of  20  degrees,  adduction 
of  45  degrees,  with  combinations  of  these  movements. 

The  thumb  can  be  flexed  and  adducted  until  it  touches  the  palmar 
base  of  the  little  finger  and  abducted  to  nearly  a  right  angle  with  the 
long  axis  of  the  palm. 

The  metacarpophalangeal  joints,  except  that  of  the  thumb,  can  be 
flexed  to  a  right  angle,  the  midphalangeal  joint  to  beyond  a  right  angle, 
the  distal  phalangeal  joints  to  very  near  a  right  angle. 

The  commonest  lesion  about  the  wrist  is  a  sprain.  Great  swelling, 
severe  pain,  and  pronounced  or  prolonged  disability  are  presumptive 
evidence  of  more  serious  injury. 

Congenital  Deformities. — Congenitally  the  digits  may  be  absent, 
supernumerary,  or  fused.  The  hand  may  be  absent,  wanting  in  its  parts, 
or  clubbed  in  any  direction.  There  may  be  contractures,  usually 
expressed  by  flexion  of  the  little  finger,  and  often  bilateral.  Exceptionally 
at  birth  the  hand  may  exhibit  the  thickening  of  myxedema,  associated 
with  the  general  conformation  of  this  lesion. 

Acquired  Deformities. — These  are  due  to  loss  of  parts  from  trau- 
matism or  destructive  ulceration,  contraction  of  scars  incident  to  the 
healing  of  extensive  wounds  or  ulcers,  atrophy,  hypertrophy  or  distor- 
tion following  chronic  inflammation  of  the  bones,  joints,  or  soft  parts, 
or  injuries  or  diseases  of  the  nerves  or  their  centres. 


Fig.   12fi 


Bilateral  Dupuytien's  contractures.     Flexion  of  fingers.     Fibrous  bands  in  palm  adherent  to 
skin.     Fifteen  years'  duration.     (Carnett.) 


Dupuytren's  Contracture. — This  occurs  in  men  past  forty,  usually  those 
who  do  hard  work  with  their  hands,  which  are  therefore  subjected  to  re- 
peated slight  trauma,  and  is  characterized  by  an  induration,  nodulation, 


THE  HAND  AND  WRIST 


347 


thickening    and  shortening  of  the   palmar  fascia  with  intimate  skin 
attachment. 

The  tendon-like  bands  first  fix  the  little  finger  in  flexion,  with  subse- 
quent involvement  of  the  other  fingers,  but  not  the  thumb.  This 
fixation  and  flex-ion  is  confined  to  the  first  and  second  joints.  The  con- 
dition is  not  attended  by  inflammatory  symptoms.  Distinction  from 
fixation  incident  to  muscular  contracture  is  made  by  the  superficial 
position  of  the  bands,  which  are  made  obviously  tense  by  efforts  to 
extend,  this  tension  being  uninfluenced  by  flexion  or  extension  of  the 
wrist. 

Fig.  127  Fig.  128 


Deformity  from  paralysis  of  the  median  nerve  (ape  hand). 


Deformity  of  paralysis  of    the    ulnar 
nerve  (claw  hand) . 

The  postural  distortions 
of  palsies  of  either  cerebral 
apoplexy,  poliomyelitis,  dif- 
fuse sclerosis,  or  peripheral 
nerve  lesions  (trauma,  pres- 
sure neuritis)  are  character- 
ized by  associated  symp- 
toms. (See  section  on 
Nerves.) 

Wrist  Drop. — Wrist  drop  incident  to  injury  of  the  musculospiral  nerve 
is  characterized  by  inability  to  extend  the  hand  or  fingers,  with  possibly 
slight  anesthesia  on  the  dorsal  surface  of  the  thumb  and  index  finger. 

Claw  hand,  in  its  typical  development  usually  due  to  injury  of  the  ulnar 
nerve,  is  characterized  by  extension  of  the  first  phalanges  and  a  flexion 
of  the  second  and  third,  with  inability  to  materially  change  this  position. 
The  fingers  can  be  neither  adducted  nor  abducted.  In  the  contractures 
incident  to  late  ulnar  palsy  the  intrinsic  hand  muscles  are  wasted,  useless, 
and  give  no  electrical  reaction,  excepting  those  of  the  thenar  eminence 
and  the  outer  lumbricals.     Ape  hand  due  to  median  paralysis  (rare  as 


348  THE  UPPER  EXTREMITY 

an  isolated  lesion)  is  characterized  by  thenar  atrophy  and  lack  of  power 
to  flex  the  second  digital  phalanges.  There  is  wasting  of  the  thenar 
and  hypothenar  eminences. 

Ischemic  contracture  (Volkinann)^  caused  by  tight  bandaging,  to  which 
children  are  especially  sensitive,  and  usually  observed  in  the  forearm, 
is  characterized  by  rigid  flexion  fixation  of  the  fingers  and  hand.  Its 
onset  after  the  application  of  dressings  is  indicated  by  severe  pain, 
followed  in  a  few  hours  by  tender  induration  and  paralysis  of  the  com- 
pressed muscles.  Thereafter  there  is  a  transitory  swelling  (days)  and  a 
rapid  atrophy  and  contracture.  Embolism,  thrombosis,  or  any  cause 
cutting  oft*  the  blood  supply  of  the  muscles  may  cause  this  same  con- 
dition. 

Occupation  paresis,  due  to  overuse  of  muscle  groups,  often  associated 
with  repeated  slight  traumata,  as  from  the  handling  of  tools,  is  character- 
ized by  progressive  paresis  and  atrophy,  and  at  times  by  moderate 
pain.  The  diagnosis  is  based  upon  the  disability  and  atrophy  of  an  over- 
used muscle  group. 

Occupation  spasm  is  characterized  by  incoordination  of  an  overused 
muscle  group  associated  with  tendency  to  painful  tonic  spasm.  Writer's 
cramp  is  a  familiar  example. 

Trigger  Finger. — ^Trigger  finger,  or  snapping  finger,  commonest  in  the 
middle  finger  of  the  right  hand  and  in  women  (Weir),  is  evidenced  by 
a  sudden  partial  locking  of  the  finger  at  one  point,  in  either  exten- 
sion or  flexion,  or  both,  followed  by  a  sudden  slightly  painful  release. 
It  may  be  due  to  a  localized  swelling  of  the  tendon,  associated  with  an 
annular  thickening  of  its  sheath  or  to  neoplasm.  It  is  often  traumatic 
in  origin. 

Stunted  useless  fingers  are  often  due  to  the  destructive  effects  of 
syphilitic  or  tuberculous  dactylitis  of  infancy. 

Repeated  trauma  of  a  joint  is  followed  by  permanent  thickening  and 
limitation  of  motion  (baseball  finger).  A  similar  condition  is  noticed 
in  the  hand  and  finger-joints  of  laborers  whose  occupation  compels  long- 
continued  or  frequently  repeated  forced  flexion  of  the  hand. 

Deformities  involving  the  joints  of  the  fingers  and  hand  due  to  the 
atrophic  (common)  or  hypertrophic  (rare)  forms  of  arthritis  deformans 
(see  section  on  bones)  may  be  trivial  or  extreme.  The  joints  (multiple 
involvement,  metacarpophalangeal  and  phalangeal)  are  enlarged,  limited 
in  motion,  and  at  times  greatly  distorted;  there  is  marked . muscular 
atrophy  and  a  tendency  to  ulnar  deflection  of  the  hand  (flipper  hand). 
There  is  a  suggestive  history,  the  onset  is  slow  (exceptionally  acute), 
and  the  complete  development  of  the  deformity  is  a  matter  of  years. 

Gouty  deformity,  which  may  be  as  pronounced  as  that  from  other 
forms  of  joint  infection,  is  characterized  in  the  beginning  by  acute  attacks 
with  complete  remissions.     Later  by  periarticular  urate  deposits  (tophi). 

The  thick  broad  hands  of  myxedema  are  associated  with  other  and 
more  marked  symptoms  of  this  condition. 

Pulmonary  osteoarthropathy,  in  its  hand  development,  is  characterized 
by  clubbing  of  the  ends  of  the  fingers. 


THE  HAND  AND  WRIST 


349 


The  deformity  due  to  the  destruction  of  the  tissue  of  the  fingers  inci- 
dent to  syringomyeha  and  the  joint  deformities  of  this  condition  are 
characterized  by  preservation  of  tactile  sensation  with  loss  of  that 
incident  to  temperature  and  pain,  and  loss  of  function  less  pronounced 
than  would  seem  proportionate  to  the  extent  of  the  lesion.  This  is 
also  true  of  the  joint  affection  of  locomotor  ataxia  (rare). 

Acromegaly  is  characterized  by  a  bilateral  overgrowth  of  the  hands 
and  feet  involving  all  the  tissues,  and  associated  with  gigantism  else- 
where, particularly  in  the  lower  jaw. 

Aside  from  enlargement  of  the  epiphyses  of  the  wrist,  rickets  does  not 
produce  marked  deformity  of  the  hand  or  fingers.  Other  and  more 
characteristic  signs  are  present  elsewhere. 

Traumatic  Affections  of  the  Hand  and  Wrist. — Sprains. — Sprain 
of  the  fingers,  hand,  and  wrist  is  characterized  by  tenderness  and  swell- 
ing in  or  around  the  joint,  pain,  and  disability. 


Fig.  1291 


Fig.  130 


Fig.  129. — Fracture  of  base  of  metacarpal  of  thumb,  separation  of  ulnar  side  of  articular  surface, 
and  dislocation  of  metacarpal  from  trapezium,  in  male,  aged  forty-six  years.  (Frequent  injury.) 
Clinical  diagnosis  of  fracture  not  difficult,  but  proper  reduction  of  both  often  difficult,  especially 
when  exact  nature  of  injury  is  not  recognized  (when  no  x-ray  is  made). 

Fig.  130. — Common  dislocation  of  thumb  backward  at  metacarpophalangeal  joint,  in  a  female, 
aged  twenty-five  years.  Clinical  diagnosis  easy,  but  ar-rays  important  to  exclude  complicating 
fracture  or  show  obstacles  to  reduction. 


'  Figs.  129  to  138.  Fractures  of  the  hand.  Outline  drawings  from  radiographs  by  Dr.  H.  K.  Pan- 
coast  in  collection  of  University  Hospital  x-ray  Laboratory;  patients  referred  by  or  from  services 
of  Drs.  Frazier,  Wood,  Musser,  Sjter,  and  Carnett,  from  dispensaries,  and  private  cases  of  Dr. 
Pancoast. 


350 


THE   UPPER  EXTREMITY 


Fig.  131 


Fig.  132 


Fig.  131. — Oblique  fissured  fracture  of  middle  metacarpal,  in  male,  aged  twenty-three  years. 
Clinical  diagnosis  uncertain,  depending  mainly  on  pain  and  local  tenderness. 

Fig.  132. — Fracture  of  distal  end  of  fifth  metacarpal,  in  female,  aged  forty  years.  Displacement 
upward  and  to  radial  side. 


Fig.  133 


Oblique  fracture  of  middle  of  shaft  ot  fifth  metacarpal;  dislocation  at  fourth  metacarpophalangeal 
joint,  with  separation  of  small  fragment  from  epiphysis  of  fourth  metacarpal.  (Latter  probably 
represents  ligamentous  attachment.)     Boy,  aged  sixteen  years. 


Fig.   134 


THE  HAND   AND  WRIST 

Fig.   135 


351 


Fig.  136 


w  ■"/ 


///"  "11 


Fig.  134. — Oblique  fissured  fracture  of  proximal  phalanx  of  fourth  finger,  in  adult  male. 

Fig.  135. — Fracture  of  base  of  proximal  phalanx  of  fifth  finger,  with  separation  of  half  the  articular 
surface,  in  adult  female.  Clinical  diagnosis  of  such  fractures  often  either  diflBcult  or  not  made, 
but  recognition  important  on  account  of  danger  of  subsequent  disability  if  not  properly  treated. 

Fig.  136. — Fracture  of  base  of  proximal  phalanx  of  index  finger,  with  separation  of  very  small 
fragment  from  articular  surface,  in  adult  male.  Clinical  diagnosis  difficult,  but  recognition  just 
as  important  as  in  the  preceding  case,  and  for  the  same  reason. 


Fig.   137 


Fig.   138 


B.  A. 

Fig.  137. — Fracture  of  proximal  end  of  middle  phalanx  of  third  finger,  with  separation  of  fragment 
of  posterior  portion  of  articular  surface,  in  adult  male.  Baseball  injury.  Fracture  shown  in  lateral 
view  only  (B),  as  is  often  the  case  in  such  injuries.  (Two  views  should  always  be  taken.)  Clinical 
diagnosis  difficult. 

Fig.  138. — Incomplete  fracture  of  distal  phalanx  of  thimib,  in  adult  female.  Only  injury  sustained 
in  fall  one  story  down  elevator  shaft.  Clinical  diagnosis  of  fracture  not  made.  Shows  in  antero- 
posterior view  (A)  only.     B,  lateral  view,  and  the  one  usually  made  in  radiographing  hand. 

Sprain  of  the  last  finger-joints  is  at  times  complicated  by  a  tearing 
away  of  the  attachment  of  either  the  extensor  or  flexor  tendon,  making 
it  impossible  to  extend  in  one  case  (hammer  finger),  or  to  flex  in  the 
other  (bayonet  finger),  the  last  digit. 


352 


THE   UPPER  EXTREMITY 


The  loss  of  power  is  characteristic.  Before  swelling  has  developed 
the  small  fragment  of  bone  may  be  felt.     The  a:;-rays  are  diagnostic. 

Sprain  of  the  wrist  is  usually  accompanied  by  tenosynovitis,  this  often 
being  the  major  lesion,  and,  if  severe  and  attended  by  great  swelling  and 
pain,  may  require  the  administration  of  ether  or  the  use  of  the  a;-rays 
to  exclude  fracture  or  luxation. 

Tenosynovitis  of  the  radial  extensors  is  regarded  as  highly  character- 
istic of  fissured  fracture  of  the  radius. 

All  sprains  characterized  by  persistence  of  disability,  pain,  local 
tenderness,  and  swelling  should  suggest  the  probability  of  a  complicating 
fracture,  for  the  diagnosis  of  which  the  a;-rays  are  needful. 

Fractures  of  the  Bones  of  the  Fingers,  Hand,  and  Wrist. — Fracture  of  the 
digits,  usually  due  to  direct  violence,  if  complete,  exhibits  characteristic 
features. 

Chipping  off  of  articular  surfaces,  usually  regarded  as  simple  sprain, 
has  been  shown  by  the  x-rays  to  be  fairly  common.  Pronounced  intra- 
articular effusion  and  continued  pain  and  tenderness  would  suggest  such 
an  injury.     The  diagnosis  must  be  made  by  the  x-rays. 


Fig.  1391 


Fig.  140 


Figs.  139  and  140. — Fracture  of  lower  end  of  radius  of  unusual  type,  in  which  the  outer  ''radial) 
and  palmar  portion  of  the  articular  surface  is  split  off.  (In  '  'Barton"  type  dorsal  portion  is  sepa- 
rated.) Complicated  by  separation  of  styloid  of  ulna  and  fracture  of  scaphoid.  Male,  aged  forty 
years.  Fig.  139,  anteroposterior  view;  Fig.  140,  lateral  view,  showing  displacement  of  lower 
radial  fragment  toward  palmar  aspect  and  upward.     Exact  clinical  diagnosis  difficult. 


1  Figs.  139  to  143.  Complicated  injuries  in  the  region  of  the  wrist.  Outline  drawings  from 
radiographs  by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray  Laboratory;  patients 
referred  from  service  of  Dr.  Siter,  and  from  dispensaries. 


THE  HAND  AND   WRIST 


353 


Fig.   141 


Fig.  142 


Fig.  141. — Complicated  injury  in  wrist  of  sailor,  aged  twenty-two  years,  resulting  from  a  fall 
into  hold  of  vessel,  comprising  the  following:  Fracture  of  styloid  of  radius,  displaced  upward; 
scaphoid  split  into  three  pieces,  1A,1B,1  C;  relative  or  actual  subluxation  of  carpus  and  hand  later- 
ally to  radial  side;  lateral  (ulnar)  dislocation  ot  cuneiform,  pisiform,  and  semilunar.  Exact  clinical 
diagnosis  of  injury  practically  impossible. 

Fig.  142.— Impacted  and  comminuted  CoUes'  fracture,  with  separation  of  tip  of  styloid  of  ulna, 
complicated  by  fracture  of  scaphoid  and  dislocation  of  pisiform,  in  adult  female.  Referred  to 
hospital  with  clinical  diagnosis  of  sprain  of  wrist,  but  possible  fracture.  Clinical  diagnosis  of  none 
of  the  separate  injuries  easy,  however. 

Fig.  143 


Colles'  fracture  (above  but  extending  into  epiphyseal  line),  with  separation  of  entire  styloid  of 
ulna,  complicated  by  fracture  of  scaphoid,  in  a  boy,  aged  fifteen  years.  (Latter  fracture  not 
determined  clinically.) 

The  tearing  away  of  a  fragment  of  bone  from  the  base  of  the  third 
phalanx  by  its  tendinous  attachment  leaves  a  joint  fixed  in  either  exten- 
sion or  flexion  (bayonet  finger,  hammer  finger). 

Fractures  of  the  metacarpal  bones,  transverse  if  from  direct  violence, 
oblique,  spiral,  or  fissured  if  from  force  applied  to  the  knuckles,  may  be 
23 


354  THE   UPPER  EXTREMITY 

obvious.  They  are,  however,  often  attended  by  but  slight  displacement, 
and  can  be  recognized  only  by  extreme  and  persistent  localized  tender- 
ness and  swelling  and  later  the  formation  of  callus.  The  tenderness  is 
elicited  either  by  pressure  at  the  seat  of  injury,  or,  the  fingers  being  flexed, 
by  suddenly  pushing  against  the  knuckle  of  the  affected  bone  toward 
the  wrist. 

Even  the  .-r-rays  may  fail  to  show  the  fracture  unless  both  antero- 
posterior and  lateral  exposures  are  made. 

An  oblique  fracture  involving  the  articular  surface  of  the  metacarpal 
bone  of  the  thumb,  usually  caused  by  a  blow  with  the  clenched  fist,  the 
impact  falling  upon  the  first  phalanx  of  the  thumb,  is  rarely  recognized 
as  such,  since  the  effusion  into  the  joint,  the  general  swelling,  and  the 
extreme  tenderness  make  the  elicitation  of  crepitus  or  mobility  difficult 
or  impossible.  The  deformity  is  strongly  suggestive  of  backward  luxa- 
tion of  the  metacarpus  upon  the  trapezium.  Since  this  injury  is 
characterized  in  its  ultimate  development  by  considerable  deformity, 
persistent  disability,  and  much  pain,  its  early  diagnosis  is  important. 

This  can  be  made  best  by  the  x-rays,  though  a  deformity  consisting  of 
backward  luxation  of  the  first  metacarpus,  which  is  readily  reduced  but  as 
easily  recurs,  is  highly  suggestive.  Later  a  bony  swelling  on  the  outer 
side  of  the  joint  attended  by  limitation  of  motion,  pain,  and  tenderness 
will  sufficiently  characterize  the  nature  of  the  affection. 

Fractures  of  the  carnal  hones,  usually  due  to  indirect  violence,  as  from 
striking  a  blow  with  the  fist  or  a  fall  upon  the  hand,  are  attended  by  marked 
and  rapid  effusion  into  the  joint,  pain,  and  extreme  local  tenderness  on 
deep  palpation.  These  fractures  are  usually  unrecognized,  and  are  the 
common  underlying  lesions  of  persistent  disability  and  gradually  in- 
creasing deformity  following  injury  which  was  supposed  to  have  been 
sprain  and  was  so  treated. 

The  scaphoid  is  the  bone  commonly  broken.  Codman  notes  as 
characteristic  symptoms,  localized  tenderness  in  the  anatomical  snuff 
box  when  the  hand  is  adducted,  swelling  on  the  radial  side  of  the  back 
of  the  wrist,  and  pronounced  disability.  These  symptoms  do  not  dis- 
appear, as  in  the  case  of  sprain,  but  either  persist  or  recur  and  are  asso- 
ciated with  limited  motions  of  the  wrist  and  hand  and  painful  spasm  on 
efforts  to  increase  this  motion,  particularly  if  these  be  made  in  the  direc- 
tion of  extension.  Carpal  fracture  may  be  complicated  by  other  fracture 
or  by  luxation. 

Fractures  of  the  Lower  Extremity  of  the  Radius. — Colles'  fracture,  the 
one  usually  encountered  in  the  region  of  the  wrist,  is  commonest  in  the 
middle  aged  as  the  result  of  a  fall  on  the  palm.  The  break  is  placed 
from  one-half  to  one  and  one-half  inches  above  the  joint  surface  of 
the  radius,  and  is  generally  slightly  oblique.  It  may  be  impacted  or 
slightly  or  extensively  comminuted.  The  lower  fragment  is  generally 
displaced  backward  and  may  be  rotated  in  the  same  direction.  There 
is  at  times  a  complicating  luxation  of  the  head  of  the  ulna,  this  portion 
of  the  bone  being  displaced  beneath  the  tendon  of  the  extensor  carpi 
ulnaris.     The  ulnar  styloid  is  sometimes  broken. 


THE  HAND  AND  WRIST 
Fig.  144 


355 


CoUes'  fracture.     (Anger.) 

The  diagnosis  is  based  upon  obvious  deformity  (silver  fork)  and,  in  the 
absence  of  impaction,  unnatural  mobility  and  crepitus.  When  the 
fracture  is  impacted,  the  deformity  is  characterized  by  radial  deflection 
of  the  hand  and  angular  deformity  which  can  be  both  seen  and  felt.  The 
upper  end  of  the  lower  fragment  projects  on  the  dorsal  surface  of  the 
wrist  above  the  articular  line,  the  lower  end  of  the  upper  fragment  form- 
ing a  similar  projection  on  the  palmar  surface  of  the  wrist. 

The  radius  is  shortened,  as  shown  by  the  elevation  ofats  styloid  to  the 
level  of  that  of  the  ulnar  or  even  above  this,  and  by  measurements  from 
the  external  humeral  condyle  to  the  radial  styloid  in  the  two  arms. 
There  is  pain,  swelling,  and  limitation  of  all  motions. 

A  fall  upon  the  back  of  the  flexed  hand  may  produce  a  Colles'  fracture, 
but  with  the  deformity  reversed,  i.  e.,  the  lower  fragment  rides  forward. 


Fig.  1451 


Fig.  14fi 


Fig.  145.- — Old  iinunited  (by  bony  union)  fracture  of  scaphoid,  in  a  male,  aged  nineteen  years. 
Neither  diagnosticated  nor  treated.     a;-ray  examination  made  to  discover  cause  of  disability. 

Fig.  146. — Recent  fracture  of  scaphoid,  with  separation  of  tip  of  styloid  of  ulna,  in  a  male,  aged 
twenty-six  years.     Clinical  diagnosis  difficult. 

1  Figs.  145  to  149.  Uncomplicated  fractures  of  the  carpal  bones.  Outline  drawings  of  radio- 
graphs by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray  Laboratory;  patients 
referred  from  dispensaries,  and  private  cases  of  Dr.  Pancoast. 


356 


THE   UPPER  EXTREMITY 
Fig.  147 


Fracture  of  cuneiform,  in  adult  female.     Not  diagnosticated  or  treated.     Radiograph,  made  three 
weeks  after  injury  to  determine  cause  of  disability.     Clinical  diagnosis  very  diflBcult,  however. 


Fig.  148 


Fig.  149 


Figs.  148  and  149. — Fracture  of  cuneiform  and  complete  anteroposterior  dislocation  of  semi- 
lunar in  left  wrist  of  male,  aged  twenty  years.  (Clinical  diagnosis,  Colles'  fracture.)  Fig.  148, 
anteroposterior  view  of  injured  wrist;  Fig.  149,  same  view  of  normal  right  wrist.  Lateral  view 
(omitted  here)  shows  rotation  of  semilunar  on  lateral  axis  about  90  degrees,  so  that  articular  surface 
for  the  OS  magnum  faces  directly  toward  the  palmar  aspect  of  the  wrist.  Pressure  on  median 
nerve.  Exact  diagnosis  not  only  not  made  clinically,  but  would  be  extremely  diflBcult  or  im- 
possible in  any  case.     Lateral  view  essential  for  i-ray  diagnosis. 


THE  HAND  AND  WRIST  357 

the  upper  backward  (gardener's  spade  deformity).  When  CoUes' 
fracture  is  complicated  by  avulsion  fracture  of  the  ulnar  styloid,  due  to  the 
pull  of  the  internal  lateral  ligament,  and  this  is  usual  when  there  is  marked 
deformity,  mobility,  crepitus,  and  local  tenderness  make  the  diagnosis 
obvious. 

Fracture  of  the  ulnar  styloid  may  result  from  violent  twisting  of  the 
wrist  in  the  absence  of  radial  fracture.  The  superficial  position  of  the 
bony  prominence  makes  the  demonstration  of  characteristic  symptoms 
easy. 

Fissured  fractures  of  the  lower  extremity  of  the  radius  running  into 
the  joint,  or  fracture  of  the  epiphyseal  line  or  near  it,  may  be  without 
displacement,  preternatural  mobility,  or  demonstrable  crepitus. 

A  diagnosis  of  fissured  fracture  of  the  radius  is  suggested  by  bone 
tenderness  on  deep  pressure  and  by  effusion  into  the  synovial  sheaths 
of  the  extensor  longus  pollicis  and  radiocarpal  extensor  (Codman), 
characterized  by  the  rapid  development  of  a  tender  fluctuating  swelling 
on  the  back  of  the  wrist-joint,  obscuring  these  tendons  and  projecting 
for  a  short  distance  upward  over  the  dorsal  aspect  of  the  radius  along 
their  course.  The  positive  assurance  of  the  presence  of  biich  a  lesion 
can  be  secured  only  by  the  x-rays. 

Fio.   150 


Recurrent  backward  dislocation  of  (proximal  phalanx  of)  thumb.  Proximal  phalanx  hyper- 
extended,  with  its  head  resting  on  the  dorsal  aspect  of  the  metacarpal.  Distal  phalanx  flexed. 
(Carnett.) 

'"'  Luxations  of  the  Hand  and  Wrist.- — Luxations  of  the  phalanges  are 
attended  by  the  characteristic  symptoms  of  gross  and  obvious  deformity, 
fixation,  and  complete  disability.  If  partial,  these  displacements  may 
escape  attention  because  of  swelling  and  tenderness. 

Radiocarpal  luxation  (rare)  forward  or  backward  exhibits  the  defor- 
mity of  Colles'  fracture,  except  that  the  radial  styloid  maintains  its  proper 
relation  to  the  ulnar  and  there  is  shortening  of  corresponding  measure- 


358 


THE  UPPER  EXTREMITY 


ments  on  the  healthy  and  injured  side  as  taken  between  the  radial 
styloid  and  a  bony  point  of  the  hand.  This  luxation  may  be  complicated 
by  Colles'  fracture. 

Radio-ulnar  luxation  from  violent  twisting  of  the  wrist  is  character- 
ized by  prominence  and  mobility  of  the  ulnar  head.  In  some  people 
this  joint  is  naturally  prominent  and  exceedingly  movable. 

Luxation  of  the  individual  carpal  bones  affects  usually  the  os  magnum 
and  the  semilunar.  The  os  magnum  dislocated  backward,  often  carry- 
ing the  semilunar  with  it,  sometimes  with  this  bone  completely  reversed, 
forms  a  projection  at  the  back  of  the  wrist  at  the  base  of  the  third  meta- 
carpal bone,  easily  recognized  unless  obscured  by  swelling  and  great 
tenderness. 

Fig.  151 


Metacarpophalangeal  dislocation. 

The  semilunar  bone,  if  displaced  forward,  in  addition  to  the  pain  and 
disability,  makes  the  upper  surface  of  the  os  magnum  unduly  prominent 
on  the  dorsum  of  the  wrist.  The  deformity  and  disability  are  similar 
to  those  of  Colles'  fracture.  The  radial  and  ulnar  styloid  exliibit  their 
normal  relation  to  each  other,  and  examination  shows  that  the  deformity 
is  placed  below  the  articular  line  and  not  above  it.  Swelling  and 
tenderness  may  make  the  diagnosis  of  this  injury  impossible  without  an 
examination  under  ether  or  the  use  of  the  rc-rays. 

Subluxation  of  the  wrist,  noted  in  young  working  people  whose  occupa- 
tion requires  constant  use  of  the  flexors  of  the  arm,  is  characterized  by  a 
widening  of  the  wrist,  at  times  a  forward  bending  of  the  lower  extremity 
of  the  radius  and  dorsal  prominence  of  the  ulna.  There  is  weakness, 
limited  extension,  and  pain  on  use.  This  condition  is  due  to  irritation  of 
the  growing  epiphysis. 

Acute  Inflammatory  Affections  of  the  Soft  Parts  of  the  Hand  and 
Wrist. — ^The  acute  dermatitis  of  rhus  poisoning  may  occasion  some 
diagnostic  difficulty  in  the  absence  of  a  history  of  exposure.  The  free 
vesiculation,  irregular  distribution,  and  moderate  constitutional  symp- 
toms are  characteristic  as  contrasted  to  erysipelas,  which,  when  it  attacks 
the  hand  complicates  an  obviously  infected  wound. 

Cellulitis. — Cellulitis  (common),  secondary  to  wounds  which  may  be 
slight,  is  characterized  by  pronounced  edematous  swelling  extending  up 


THE  HAND  AND  WRIST 


359 


the  arm,  most  marked  on  the  back  of  the  hand.  It  is  often  preceded  by 
the  red  tender  edematous  streaks  of  lymphangitis,  is  accompanied  by 
the  constitutional  symptoms  of  sepsis,  and  may  be  complicated  or  fol- 
lowed by  suppurative  inflammation  of  the  epicondyloid  or  axillary 
glands.  In  exceptionally  virulent  infections  the  constitutional  symp- 
toms may  precede  by  some  hours  the  local  swelling. 

Furuncle. — Furuncle,  or  boil,  usually  on  the  dorsal  aspect  of  the  hand, 
wrist,  or  fingers,  begins  with  a  folliculitis,  which  is  stimulated  to  further 
development  by  slight  traumatism,  usually  that  incident  to  the  rubbing  of 
a  cuff  or  glove.  It  is  distinguished  from  a  poisoned  wound  by  its  history 
of  onset,  its  slower  course,  and  fairly  sharp  limitation. 

Paronychia. — Paronychia  usually  begins  with  heat,  redness,  and  throb- 
bing pain,  generally  at  the  base  of  the  nail,  where  there  shortly  forms  a 
yellow  bleb,  from  which,  on  puncture,  one  or  two  drops  of  pus  are  dis- 
charged. This  inflammation  may  almost  painlessly  involve  the  entire 
nail  base  or  may  burrow  wide  of  this  beneath  the  epidermis  (subcutic- 
ular), forming  a  pustule.     Often  it  is  the  starting  point  of  felon. 


Ftg.   152 


Diffuse  syphilitic  paronychia.      (Taylor.) 


Cellulitis  of  the  Finger. — Here  the  pain  is  severe,  throbbing,  constant. 
The  finger  is  swollen  and  excessively  tender,  there  is  accompanying 
lymphangitis  and  moderate  fever.  The  cellular  tissue  of  the  finger  is 
the  portion  first  involved  in  the  inflammation  (subcutaneous);  if  the 
condition  be  unrelieved,  the  tendinous  sheaths  become  infected;  finally 
the  bones  (distal  phalanx)  and  joints  (midphalangeal).  The  swelling 
usually  terminates,  at  least  in  its  hyperacute  form,  before  reaching  the 
middle  third  of  the  palm. 

If  the  tendon  sheaths  of  the  thumb  or  little  finger  are  affected,  the 


360 


THE  UPPER  EXTREMITY 


infection  more  rapidly  and  surely  reaches  the  wrist-joint  and  forearm 
beneath  the  deep  flexors. 

The  common  cause  of  tendon  sheath  infection  is  environing  cellulitis, 
particularly  when  the  cause  of  this  also  produced  a  predisposing  con- 
gestion of  the  tendinous  sheaths,  as  in  the  case  of  those  infected  fingers 
which  so  frequently  follow  rowing  or  handling  tools  after  a  period  of  rest. 

The  distinction  between  subcutaneous  cellulitis  and  involvement  of 
tendon  sheaths,  bone,  or  joint  should  be  made  by  free  incision  and 
direct  examination. 


Fig.   153 


Keratitis  palmaris  (arsenical). 


Shot-like  nodules  of  epithelium  embedded  in  the  thick  skin. 
(HartzeU.) 


Palmar  Abscess. — Palmar  abscess,  usually  secondary  to  digital  cellu- 
litis, also  caused  by  wound,  sprain,  or  contusion,  with  blood  effusion  into 
and  beneath  the  palmar  fascia,  is  characterized  by  severe  pain,  fever, 
prostration,  and  swelling  of  the  entire  hand,  which  becomes  like  a  pus- 
soaked  sponge.  Because  of  the  dense  tissues  lying  in  the  palm,  the 
swelling  and  edema  are  usually  more  pronounced  on  the  dorsal  aspect. 

The  infection  travels  up  the  wrist  and  into  the  cellular  structures  of 
the  forearm.  It  may  involve  the  wrist-joint  in  a  suppurative  arthritis, 
and  commonly  causes  sloughing  of  the  tendons. 

Chronic  Inflammation  of  the  Soft  Parts  of  the  Hand. — Erysipeloid.— 
Erysipeloid  is  an  affection  common  to  those  who  handle  fish,  oysters, 
and  raw  meat,  characterized  by  a  slowly  spreading  (weeks),  dusky  red 
infiammation  of  the  skin  of  the  hand,  usually  the  fingers,  exhibiting 
raised  borders  and  all  the  features  of  an  erysipelas,  with  the  exception 
of  the  progression  and  the  constitutional  symptoms  of  the  latter.  Of 
the  inflammatory  skin  lesions,  psoriasis,  keratitis  palmaris,  and  derma- 
titis repens  all  from  their  obstinate  persistence  should  be  recognized 
on  sight. 


THE  HAND  AND  WRIST 


361 


Dermatitis  vegetans  (rare),  without  obvious  cause,  is  characterized  by 
its  slow  course  and  persistence  in  the  absence  of  antiseptic  treatment. 


Fig.  154 


Dermatitis  vegetans.      (Hartzell.) 
Fig.   155 


Dermatitis  repens.    Slowly  spreading  (months),  superficial,  exfoliating  dermatitis.     (Hartzell.) 


362 


THE  UPPER  EXTREMITY 


Traumatic  Ulcers. — ^Traumatic  ulcers,  superficial,  irregular  in  shape, 
indolent,  but  slightly  indurated,  exhibiting  areas  of  healing  and  breaking 
down,  and  not  painful,  are  such  as  are  found  on  hands  subject  to  repeated 
slight  trauma  without  opportunity  for  cleanliness  and  protection.  These 
lesions  are  observed  on  the  hands  of  guides,  masons,  bricklayers,  wood- 
choppers,  etc. 

Syphilitic  Ulcers. — Syphilitic  ulcers  may  appear  in  the  form  of  chancre, 
secondary  or  tertiary  lesions. 

Chancre,  often  beginning  in  a  hang-nail  or  an  unobserved  scratch  or 
abrasion,  appears  as  a  chronic,  slowly  spreading,  often  painful,  persistent 
ulcer,  on  any  part  of  the  fingers  or  hand,  but  commonly  at  the  base 
of  the  nail.     Often  there  is  in  the  latter  case  an  associated  swelling  of 


Fig.   156 


Palmar  syphilide  (late  lesion).     (Hartzell.) 

the  entire  phalanx.  In  appearance  these  ulcers  do  not  resemble  chancres 
seen  on  the  genitalia;  the  surrounding  induration  is  not  sharply  circum- 
scribed. 

The  diagnosis  must  be  based  upon  their  persistence,  the  difficulty  of 
explaining  their  presence  on  any  other  basis,  the  associated  epitrochlear 
and  axillary  enlargement,  and  the  finding  of  the  spirochete.  Usually 
it  is  not  made  until  the  secondary  eruption  develops.  Physicians  are 
peculiarly  subject  to  such  lesions. 

Chancre  over  the  knuckles  or  back  of  the  hand,  usually  secondary  to  a 
tooth  wound,  conforms  more  to  the  type  of  a  venereal  sore  in  that  it  is 
rounded  or  oval,  indolent,  persistent,  and  slow  in  progression. 

The  inoculation  of  virulent  sepsis  and  syphilis  may  occur  at  the  same 
time,    the   cellulitis,    lymphangitis,  and  lymphadenitis   of   the   former 


THE  HAND  AND  WRIST 


363 


completely  masking  the  latter  for  weeks  or  months.  Moreover,  chronic 
sepsis  exhibits  at  times  skin  manifestations  not  unlike  those  of  secondary 
syphilis.  A  diagnosis  under  such  circumstances  must  be  made  by  the 
therapeutic  test,  by  the  development  of  typical  lesions,  and  possibly  by 
finding  the  spirochete.  This  mixed  infection  is  exceedingly  rare,  is 
seen  mainly  in  doctors  infected  during  operation,  and  in  them  is  fre- 
quently imaginary. 

Fig.   157 


^^ 


Dactylitis  syphilitica.     (Taylor.) 
Fig.  158 


attum 
Dactylitis  syphilitica. 


(Taylor.) 


Secondary  lesions  of  syphilis,  usually  non-ulcerating,  commonly  appear 
in  the  form  of  papular  exfoliating  palmar  lesions.  Associated  symptoms 
make  the  diagnosis. 

Tertiary  lesions  are  characterized  by  nodulations  which  exceptionally 
ulcerate  and  slowly  extend  in  a  circinate  form. 

The  diagnosis  is  based  upon  the  indolence  of  the  lesions,  their  circinate 
borders,  and  associated  symptoms. 


364  THE   UPPER  EXTREMITY 

Circumscribed  gumma  involving  the  soft  parts  of  the  hand  is  rare.  It 
corresponds  in  type  to  gummata  in  general. 

Ulcerating  sinuses  incident  to  the  breaking  down  of  a  gunmaatous 
lesion  of  the  phalanges  of  infants  are  common  manifestations  of  heredi- 
tary syphilis. 

Deep  trichophytosis  may  form  a  superficially  ulcerating  lesion,  the 
diagnosis  of  which  can  be  established  only  by  the  microscope. 


Fig.   159 

1 

gH^gg^; 

-  *»M 

j^^^^^B 

Deep  trichophytosis.     (Hartzell.) 

Tuberculosis. — Tuberculosis  of  the  soft  parts  of  the  hand  and  fingers 
is  rare,  if  the  chronic  ulcerations  and  papillary  outgrowth  observed 
in  the  hands  of  those  working  in  the  dissecting  room  be  excepted. 
These  lesions  appear  either  in  the  form  of  small  clusters  of  warts,  ulcerat- 
ing or  pustulating  at  the  base,  or  as  nodular,  indolent  ulcerations.  The 
diagnosis  is  based  upon  the  finding  of  the  tubercle  bacillus. 

Lupus  may  assume  any  of  its  forms,  i.  e.,  hyperemic,  verrucous, 
nodular,  or  superficially  or  deeply  ulcerating.  In  the  last  type  it  is 
ultimately  attended  by  deforming  and  crippling  contracture.  It  begins 
in  youth  on  the  dorsal  aspect,  is  extremely  indolent  (years),  and  is 
resistant  to  cleansing  and  protecting  treatment. 

Tuberculous  Tenosynovitis. — A  chronic  painless  tenosynovitis  is  the 
commonest  tuberculous  lesion  involving  the  soft  parts  of  the  hand. 
Indolent,  fusiform,  soft  swellings  form  along  the  course  of  the  tendons, 
sometimes  the  flexors  of  the  fingers;  usually  the  involvement  is  of  the 
com  mon  flexor  sheath.  The  palm  is  gradually  (years)  distended  by  a 
soft  painless  tumor  which  also  appears  on  the  wrist.  The  communication 
of  ^he  swellings  beneath  the  annular  ligament  is  shown  by  fluctuation. 
Usually,  because  of  the  rice-like  bodies  with  which  the  synovial  sac 
is  filled,  there  is,  in  addition  to  fluctuation,  a  chain-like  grating  on 


THE  HAND  AND  WRIST  365 

manipulation.  There  is  muscular  atrophy  and  limitation  of  flexion,  or, 
when  the  tendons  themselves  are  fibrillated  and  destroyed,  complete  loss 
of  motion.  Involvement  of  the  sheath  of  the  extensors  is  manifested 
by  a  globular  swelling  on  the  back  of  the  wrist-joint.  In  the  fun- 
gating  form  of  tuberculous  tenosynovitis,  softening  and  sinus  formation 
occur.  The  seat  of  the  swelling,  its  indolence,  fluctuation,  extent, 
and  chain-like  grating  when  this  is  present  suggest  the  diagnosis  of  a 
condition  which  is  not  accounted  for  on  any  other  than  a  tuberculous 
basis. 

GonorrlieaJ  fenosynovitis  is  more  acute  in  onset  and  subsidence. 
Lipoma  of  the  palm  may  cause  an  enlargement  exactly  simulating  teno- 
synovitis of  the  flexor  sheath.  It  gives  no  crepitation  and  does  not 
cause  muscular  atrophy  or  fixation  to  the  same  degree.  The  diagnosis 
is  usually  made  by  operation. 

Epitheliomatous  Ulcers. — Epitheliomatous  ulcers,  found  on  the  dorsal 
surface  of  the  hands  and  fingers,  usually  begin  in  warts  or  cicatrices,  and 
are  characterized  by  the  persistence  of  ulceration  and  slow  extension. 
Later,  the  indurated,  destructive,  often  fungating  ulcer  with  glandular 
involvement  is  unmistakable.  The  chancre  is  more  rapid  in  evolution 
(weeks),  the  gumma  begins  as  a  dermal  or  subdermal  induration  which 
softens  and  breaks  down  (weeks  or  months). 

Early  diagnosis  can  be  made  only  by  microscopic  examination  of  the 
excised  lesion. 

Trophic  Ulcers. — Trophic  ulcers,  incident  to  nerve  lesion,  are  accom- 
panied by  the  changes  in  circulation  and  nutrition  characteristic  of  the 
underlying  lesion.    These  ulcers  are  persistent,  painless,  and  progressive. 

Digital  cellulitis,  dependent  upon  syringomyelia,  is  highly  destructive. 
There  is  usually  fever,  but  aside  from  this  the  constitutional  symptoms 
are  slight. 

The  diagnosis  in  the  case  of  syringomyelia  is  based  upon  the  preserva- 
tion of  tactile  sensation  and  the  loss  of  sensation  for  temperature  and  pain. 

Gangrenous  Affections  of  the  Hand. — Acute  traumatic  gangrene 
following  extensive  injury  exhibits  the  forms  and  symptoms  of  the 
affection  as  observed  in  other  parts  of  the  body  (p.  99). 

Carbolic  Acid  Gangrene. — Carbolic  acid  gangrene,  which  may  follow 
the  continued  application  of  a  weak  solution  (1  to  100),  is  characterized 
by  a  numb,  white  area,  becoming  completely  anesthetic,  cold,  black, 
and  gangrenous. 

Diabetic  Gangrene. — Diabetic  gangrene,  characterized  by  the  rapid  or 
slowly  progressive  sloughing  of  tissues  out  of  proportion  to  the  original 
trauma  or  infection,  is  suggested  by  this  very  fact  and  corroborated 
by  urinary  examination. 

Arteriosclerotic,  or  senile,  gangrene,  an  affection  of  old  age,  which  may 
occur  in  younger  people,  exhibits  the  prodromal  symptoms  of  tingling 
pain,  loss  of  heat,  and  impaired  strength  and  motility,  followed  by 
vesiculation  of  the  skin  and  dry  gangrene. 

Symmetrical  gangrene,  or  Raynaud's  disease,  is  characterized  by 
extreme  pallor,  coldness  of  the  part,  attended  by  blunting  of  sensation, 


366  THE  UPPER  EXTREMITY 

succeeded  in  turn  by  duskiness,  bleb  formation,  anesthesia,  and  com- 
plete or  partial  local  death.  It  is  usually  bilateral  and  involves  more 
than  one  finger  of  each  side. 

Embolic  Gangrene. — Embolic  gangrene,  characterized  by  sudden 
onset,  without  previous  pronounced  symptoms,  in  the  presence  of  a 
valvular  heart  lesion,  is  marked  by  the  sudden  circulatory  failure, 
followed  by  typical  symptoms  of  death  of  the  part.  The  seat  of  arterial 
obstruction  can  usually  be  determined  by  palpation  of  the  brachial 
artery. 

Inflammatory  Affections  of  the  Bones  and  Joints  of  the  Hand 
and  Wrist. — Acute  inflammatory  afi^ections  of  the  bones  and  joints  of 
the  hand  and  wrist,  in  their  suppurative  form,  are  nearly  always  second- 
ary to  cellulitis  and  suppurative  tenosynovitis. 

Acute  post-traumatic,  non-suppurative  inflammation  of  the  bones 
and  joints,  characterized  by  persistent  pain  and  tenderness  on  deep 
pressure,  swelling,  usually  obscured  by  exudate  into  the  surrounding 
soft  parts,  and  fixation  of  the  joint  in  the  position  which  allows  of  great- 
est distention  of  its  capsule  (slight  flexion),  is  usually  suggestive  of 
fracture,  for  the  detection  of  which  the  x-rays  are  needful. 

Acute  Gouty  Periarthritis. — Acute  periarthritis  of  gout  closely  simu- 
lates infection,  but  is  characterized  by  an  absence  of  history  of  trauma, 
sudden  onset,  swelling,  heat  and  redness,  and  the  absence  of  either 
lymphangitis  or  pronounced  constitutional  symptoms  of  septic  absorp- 
tion.    Tophi,  when  present,  are  diagnostic. 

Gonorrheal  Arthritis. — Gonorrheal  arthritis  is  characterized  by  acute 
inflammatory  symptoms,  joint  fixation,  severe  pain,  usually  marked 
periarticular  heat,  redness,  and  swelling.  The  finger-joints  and  that 
of  the  wrist  are  especially  subject  to  this  involvement.  It  is  usually 
complicated  by  tenosynovitis. 

The  diagnosis  is  based  upon  the  sudden  onset  of  joint  inflammation, 
for  which  no  other  cause  than  gonorrheal  infection  can  be  found. 

Acute  Rheumatoid  Arthritis. — This  is  distinguished  from  rheumatic 
arthritis  only  by  the  persistence  of  the  joint  lesions  (polyarticular  and 
bilateral),  usually  periarticular,  with  ultimate  pronounced  limitation  of 
motion,  distortion,  and  deformity,  best  marked  in  the  midphalangeal 
and  metacarpophalangeal  joints.  The  affection  develops  in  the  young 
with  fever.  It  is  usually  called  rheumatic.  The  functional  prognosis 
is  bad. 

Chronic  inflammation  of  the  bones  and  joints  of  the  hand  and  wrist 
may  be  due  to  repeated  slight  tramna,  infection  of  unknown  origin 
(rheumatoid  arthritis),  tuberculosis,  syphilis,  or  syringomyelia. 

Chronic  Traumatic  Arthritis. — Chronic  inflammation  incident  to  re- 
peated slight  trauma,  exhibited  most  frequently  in  the  wrist-joint,  but 
possible  in  any  of  the  articulations  of  the  hand,  is  characterized  by  a 
gradual  thickening  and  enlargement  both  of  bone  and  periarticular 
tissue,  producing  deformity  and  disability.  It  is  observed  in  young 
people  who  are  compelled  to  use  their  hands  constantly  without  oppor- 
tunity for  rest,  or  in  those  who  are  subjected  to  slight  injury,  and  who 


THE  HAND  AND  WRIST  367 

have  no  opportunity  for  complete  recovery  from  the  same.  In  its  early 
course  it  resembles  tuberculous  involvement,  nor  can  it  be  distinguished 
from  this  except  in  its  progress,  there  being  no  tendency  toward  soften- 
ing nor  abscess  formation. 

Tuberculous  Arthritis. — ^Tuberculous  arthritis  often  follows  slight 
traumatism.  It  is  observed  in  the  wrist  of  the  adult;  in  the  metacarpo- 
phalangeal articulations  in  children. 

In  the  early  stages  of  tuberculous  arthritis  of  the  wrist,  pain,  aggra- 
vated by  use,  partial  fixation,  muscular  atrophy,  and  often  a  point  of 
tenderness  on  deep  pressure,  are  the  symptoms.  The  wrist,  hand,  and 
fingers  are  held  slightlv  flexed. 

A  distinction  from  the  continued  disability,  tenderness,  and  swelling, 
following  fissured  fracture,  can  be  made  only  by  the  x-r&js,  and  by  the 
fact  that  tuberculosis  follows  slight  rather  than  severe  trauma. 

Tuberculous  arthritis  is  distinguished  from  arthritis  produced  by 
overuse  only  by  the  history  and  the  result  of  brief  rest  in  the  latter  case. 

Since,  preceding  a  general  joint  invasion,  the  tuberculous  process  is 
often  limited  to  the  radial  epiphysis,  the  base  of  the  metacarpus  or  the 
carpus,  an  early  diagnosis  of  such  localization,  suggested  by  local  tender- 
ness, made  possible  often  by  the  a-rays,  is  highly  desirable.  The  slow 
(months)  progression  of  the  tuberculous  process,  forming  a  spindle- 
shaped  swelling  accentuated  by  muscular  atrophy,  involving  the  ten- 
dons and  their  sheaths  and  fixing  them,  and  ultimately  softening  and 
discharging  through  fistula  which  lead  to  carious  bone,  is  characteristic. 

Fro.   160 


TubeiL-uluai.s  ui  wrist  and  carpal  joints,  witli  suppurating  sinus  on  dorsiun  of  hand.  Eighteen 
months'  duration.  Doughy  infiltration  of  soft  tissues.  Grating  of  articular  surfaces  on  manipula- 
tion.    Motion  limited  in  all  directions.     Similar  lesion  in  knee-joint.     (Carnett.) 

Tuberculosis  of  the  metacarpals  and  phalanges,  called  spina  ventosa, 
and  usually  an  affection  of  childhood,  is  characterized  by  a  painless, 
cylindrical  swelling,  at  first  of  the  bone,  later  involving  the  joint.  It  is 
followed  (weeks  or  months)  by  redness  and  edema  of  the  overlying  skin, 
softening,  and  discharge  of  a  curdy  pus  from  sinuses  which  lead  to 
dead  bone.  It  results  in  pronounced  deformity  of  the  fingers  and  bony 
ankylosis.     Recovery  may  take  place  without  suppuration. 

Syphilitic  Inflammation. — Syphilitic  inflammation  of  the  bones  and 
joints  of  the  hand  presents  a  picture  so  like  that  of  a  tuberculous 
involvement  that  the  differential  diagnosis  from  the  appearance  alone 
is   impossible.     Associated  symptoms   and  signs   of  syphilis   and   the 


368 


THE  UPPER  EXTREMITY 

Fig.   161 


Angioma,  probably  with  lipomatous  and  fibromatous  admixture.  Dense,  hard  in  place,  unattached 
to  the  underlying  skin,  and  movable  on  the  bone  below.  Varying  in  size  in  accordance  with  the 
amount  of  local  venous  congestion. 


Fig.   162 


Traumatic  epithelial  cyst,  usually  be- 
neath the  skin,  which  is  not  adherent. 
Vary  from  size  of  pea  to  that  of  walnut; 
contents  similar  to  that  in  sebaceous 
cyst;  may  follow  trauma  by  many  years. 
(Berger.) 


therapeutic  test  furnish  the  means  of 
differentiation.  This  test  is  futile  when 
fistulse  have  formed. 

As  in  the  case  of  tuberculosis,  anky- 
losis or  marked  atrophy  or  distortion  of 
the  finger  may  result  in  the  absence  of 
suppuration. 

Tumors  of  the  Hand  and  Wrist. 
— Multiple  Angiomata. — Multiple  angio- 
mata,  either  capillary  or  venous,  are 
not  infrequently  seen  on  the  back  of 
the  hand.  Lipoma,  fibroma,  and  seba- 
ceous cysts  are  rare. 

Epithelial  Cysts. — Epithelial  cysts,  ob- 
served on  the  palmar  surface  of  the 
finger,  exceptionally  the  palm,  form 
small,  hard,  rounded,  non-inflammatory 
skin  tumors,  slow  in  growth. 

The  diagnosis  is  based  upon  excision 
and  microscopic  examination.  Neu- 
roma and  neurofibroma  of  traumatic 
origin,  forming  about  small  encysted 
foreign  bodies,  are  occasionally  found. 
The  diagnosis  must  be  by  the  micro- 
scope. 

Ganglion. — Ganglion  forms  a  rounded 
elastic    tumor,     the    prominence    and 


THE  HAND  AND  WRIST 


369 


tension  of  which  can  be  markedly  altered  by  flexion  and  extension 
of  the  joint  near  which  it  occurs.  Its  appearance  often  follows  slight 
traumatism  or  overuse,  and  its  usual  position  is  on  the  back  of  the  wrist, 
to  the  ulnar  side  of  the  extensor  carpi  radialis,  where  it  causes  little 
discomfort  aside  from  the  deformity.  ^Mien  placed  in  front  of  the 
wrist,  the  pressure  on  nerves  may  cause  distressing  pain  and  disability. 
Exceptionally,  these  tense,  rounded  tumors,  are  found  on  the  palmar 
surface  of  the  metacarpophalangeal  joints. 

The  diagnosis  is  based  upon  the  position  of  the  tumor,  its  non-inflam- 
matory character,  its  slight  mobility,  its  pronounced  change  in  tension 
dependent  upon  joint  position,  and  finally,  upon  excision.  The  contents 
are  usually  jelly-like  and,  though  the  cysts  are  adherent  to  the  sheath 
of  the  tendons,  they  usually  originate  from  the  capsule  of  the  joint  itself. 

Fig.  103 


Multiple  enchondroma  of  the  left  hand.      (v.  Bruns.) 


Multiple  Enchondromata. — Multiple  enchondromata  form  hard,  pain- 
less tumors  which  are  fixed  to  the  bone  and  grow  slowly  (years).  Sar- 
comatous degeneration  is  characterized  by  rapidity  of  growth  and 
early  metastases. 

Sarcoma. — Sarcoma  of  the  melanotic  variety  may  start  in  a  nevus, 
particularly  about  the  ungual  region.  It  is  usually  of  the  spindle-cell 
variety,  occurs  in  young  people,  and  is  characterized  by  rapid  growth 
and  the  obliteration  of  the  surrounding  bone. 

Fibrosarcoma. — Fibrosarcoma  forms  a  tumor,  usually  on  the  palmar 

surface  of  the  fingers,  attached  to  the  flexor  sheaths  and  attended  bv 

no  s}Tnptom  other  than  the  inconvenience  caused  by  this  growth.     It 

may  remain  (years)  long  standing  and  local,  closely  simulating  a  fibrous 

24 


370 


THE  UPPER  EXTREMITY 


thickening.  Rapid  growth  of  such  an  apparent  thickening  should 
suggest  possible  malignancy.  The  diagnosis  should  be  based  upon 
excision  and  microscopic  examination. 

Epithelioma.— Epithelioma,  originating  in  an  ulcer,  cicatrix,  or  wart, 
is  marked  by  a  persistent,  slowly  (weeks  or  months)  spreading, 
destructive  ulcer.  The  diagnosis  is  made  by  microscopic  examina- 
tion. It  is  most  malignant  when  it  originates  in  congenital  warts 
(Volkmann). 

THE  FOREARM. 

Malformations  are  obvious.  The  forearm  may  be  absent  or  the  bones 
may  only  partially  develop.  The  radius  is  more  frequently  involved 
than  the  ulna. 

Fig.  164 


Brachioradialls  (.supinator  longus). 


Kadial  artery. 


Prominence  of  short  extensor  ten- 
dons of  the  thumb. 


Thenar  eminence. 


Internal  condyle. 
Brachial  artery. 
Biceps  tendon. 

Prorainence  of  flexor  and  pronator 
muscles. 


Pronator  radii  teres  m. 


Flexor  suhlimis  digitorum  m. 


Flexor  carpi  ulnaris  m, 


Ulnar  artery. 

Palmaris  longns  tendon. 

Median  nerve. 

FJexor  carpi  radialls  m. 

liine  indicating  wrist-joint. 

Joint  bet.  1st  and  2d  row  carp,  bones. 

Pisiform  bone. 


Deep  palmar  arch 
Hypothenar  eminence. 

Superficial  palmar  arch. 

Palmar  digital  arteries  and  nerves. 


Surface  anatomy  of  the  forearm.     (G.  G.  Davis.) 


THE  FOREARM 


371 


Traumatism. — ^The  effects  of  traumatism  may  be  manifested  by  con- 
tusion, subcutaneous  rupture  of  muscle  or  tendons,  wounds,  fracture,  or 
luxation. 

Subcutaneous  rupture  of  tendons  or  muscles,  usually  the  result  of  mus- 
cular action,  is  characterized  by  sudden,  sharp  pain,  disability  in  so  far 
as  the  muscle  or  tendon  affected  is  concerned,  localized  tenderness  and 


Fig.  165 


Triceps  m 


Olecranon  process. 


Subcutaneous  surface  of  the  ulna. 


Styloid  process  of  the  ulna. 


External  condyle. 
Depression  for  head  of  radius. 


Prominence  formed  by  the  extensor 
and  sapinator  muscles. 


Posterior  radial  tubercle,  marking 

the  middle  of  the  radius. 
Styloid  process  of  the  radius. 

Anatomical  snufi  box. 


Surface  anatomy  of  the  forearm.     (G.  G.  Davis.) 

swelling,  and,  if  the  rupture  be  extensive  and  superficial  in  the  case  of 
the  muscle,  or  complete  in  the  case  of  the  tendon,  the  almost  immediate 
formation  of  a  soft  tumor,  deep  pressure  into  which  shows  a  break  in 
continuity,  increased  by  muscular  contraction. 

Acute   Tenosynovitis. — Acute  tenosynovitis   is   a  common  expression 
of   overuse   occurring   frequently   in   masons,   carpenters,  oarsmen,  or 


372 


THE   UPPER  EXTREMITY 


washerwomen,  who  take  up  their  work  after  a  period  of  rest.  It  is 
characterized  by  tenderness  and  crepitation  along  the  course  of  the 
tendons  J  particularly  the  radiocarpal  and  the  thumb  extensors.  There 
is  pain  on  motion  and  often  slight  redness  of  the  overlying  skin.  Crep- 
itation is  best  detected  by  grasping  the  forearm  just  above  the  wrist 
and  causing  the  patient  to  repeatedly  flex  and  extend  the  hand  and 
thumb. 


Fig.  1661 


Fig.  167 


Figs.  166  and  167. — Fracture  of  radius  near  lower  end,  in  a  girl,  aged  ten  years,  resulting  from 
fall  on  hand  while  roller  skating.  Anteroposterior  view.  Fig.  166,  shows  no  deformity;  lateral. 
Fig.  167,  shows  angular  deformity  toward  pahnar  aspect,  degree  of  which  was  not  determinable 
clinicall.y.     (Important  in  female.)     Clinical  diagnosis  of  fracture  easy.) 


1  Figs.  166  to  192.  Fractures  of  the  lower  ends  of  the  bones  of  the  forearm.  Outline  drawings 
from  radiographs  by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray  Laboratory; 
patients  referred  by  or  from  services  of  Drs.  Wood,  Camett,  and  Siter,  from  dispensaries,  and 
private  cases  of  Dr.  Pancoast. 


THE  FOREARM  373 

Fig.  168  Fig.  169 


Fig.  168. — Fracture  of  radius,  lower  end,  just  above  epiphyseal  line,  in  a  boy,  aged  seventeen 
years,  resulting  from  fall  on  hand  while  roller  skating.  Anteroposterior  view.  (No  displace- 
ment shown  in  either  view.)  This  type  corresponds  to  the  Colles  fracture  in  the  adult,  being 
usually  a  little  higher  than  level  of  latter.  Epiphyseal  separations  and  fractures  just  above  the 
line  (of  Colles)  are  less  frequent.  Clinical  diagnosis  not  difficult,  although  fracture  was  more  or 
less  impacted. 

Fig.  169. — Typical  example  of  impacted  Colles'  fracture,  in  adult  male.  No  displacement  in 
either  direction;  mobility  and  crepitus  absent.  Clinical  diagnosis  depends  upon  history  of  injury, 
pain,  local  tenderness,  and  swelling.     Anteroposterior  view. 


Fig.  170 


Fig.  171 


Figs.  170  and  171. — Typical  example  of  so-called  "Barton"  fracture — splitting  ofif  of  posterior 
portion  ofj[articular  surface.  Adult  male,  with  chronic  atrophic  arthritis  of  wrist.  (Note  close 
approximation  of  carpal  bones  due  to  loss  of  cartilage.)  Fracture  shows  in  lateral  \-iew  only,  as 
is  often  the  case  (Fig.  171).     No  deformity,  but  diagnosis  of  fracture  not  difficult  clinicallj'. 


374 


THE  UPPER  EXTREMITY 
Fig.  172 


Unusual  type  of  fracture,  in  adult  male.  Radiograph  two  weeks  after  injury.  Eesembles 
'  'Barton"  type  more  than  '  'CoUes."  Considerable  comminution  at  articular  surface.  Clinical 
diagnosis  of  fracture  not  diflBcult,  but  x-ray  important  in  proper  reduction.  Anteroposterior 
view. 


Fig.  173 


Fig.  174 


Fig.  173. — Typical  example  of  the  common  '  'automobile  fracture,"  in  an  adult  male.  (Direct 
violence  from  back  kick  of  crank.)  A  fissured  fracture  through  the  base  of  styloid  process  of  radius. 
Clinical  diagnosis  often  difficvdt,  depending  mainly  on  history,  pain,  and  local  tenderness.  Fre- 
quently overlooked.     Anteroposterior  view. 

Fig.  174. — CoUes'  fracture,  with  comminution  into  joint,  in  an  adult  female.  Also  separation 
of  tip  of  styloid  of  ulna,  which  x-rays  have  shown  occurs  in  at  least  half  these  fractures,  especially 
in  falls  backward  on  hand,  as  when  slipping  on  ice.  Anteroposterior  view  after  reduction;  good 
apposition. 


THE  FOREARM  375 

Fig.  175  Fig.  176 


Figs.  175  and  176. — Epiphyseal  separation  lower  end  radius,  in  a  boy,  aged  eleven  years.  Small 
fragment  of  diaphysis  separated  from  posterior  and  outer  edge  ■ndth  epiphysis.  Anteroposterior 
view,  Fig.  175,  indicates  no  deformity  laterally,  but  lateral  -vaew,  Fig.  176,  shows  dorsal  displace- 
ment of  radial  epiphysis,  needing  correction.  Clinical  diagnosis  not  difficult,  especially  when 
such  displacement  exists.  (Without  latter,  x-rays  always  negative  unless  fracture  accompanies 
epiphyseal  injury.) 


Fig.  177 


Fig.  178 


Figs.  177  and  178. — Epiphyseal  separation  radius,  with  more  extensive  fracture  of  diaphysis  than 
preceding,  in  a  girl,  aged  thirteen  years.  Line  of  fracture  starts  posteriorly  about  level  of  Colics', 
then  runs  downward  and  forward  into  epiphyseal  line,  whence  break  continues  as  separation  of 
epiphysis.  Anteroposterior  view.  Fig.  177,  indicates  no  lateral  displacement,  but  also  no  certain 
evidence  of  radial  injury.  It  does  show  a  fracture  through  ulnar  epiphysis  at  base  of  styloid. 
Lateral  view.  Fig.  178,  shows  dorsal  displacement  of  epiphysis  and  fragment  of  diaphysis  of  radius. 
No  difficulty  about  clinical  diagnosis. 


376 


THE   UPPER  EXTREMITY 


Fig.  179 


Fig.  180 


Fig.  179. — Colles'  fracture  at  higher  level  than  usual,  and  lower  fragment  comminuted  into 
joint,  accompanied  by  separation  of  both  base  and  tip  of  styloid  of  ulna,  in  an  adult  female. 
Anteroposterior  view  after  reduction.  Clinical  diagnosis  of  fracture  not  difficult,  but  a;-rays  im- 
portant in  reduction. 

Fig.  180. — Comminuted  Colles'  fracture,  rather  high  level  and  oblique  in  direction,  with  separa- 
tion of  styloid  of  ulna,  in  an  adult  male.  Joint  not  involved.  Anteroposterior  view  after  reduc- 
tion.    Clinical  diagnosis  not  difficult.     X-rays  made  to  determine  apposition  of  fragments. 


Fig.  181 


Fig.  182 


Figs.  181  and  182. — Comminuted  Colles'  fracture  and  separation  of  styloid  of  ulna,  in  an  adult 
male.  Anteroposterior  view.  Fig.  182,  shows  lateral  displacement  to  radial  side.  (Note  altered 
relation  in  levels  of  styloids  of  two  bones.)  Lateral  view,  Fig.  181,  shows  dorsal  and  upward 
displacement  of  lower  fragment.  No  difficulty  in  clinical  diagnosis  of  fracture,  but  x-rays  important 
to  show  deformities  requiring  correction. 


THE  FOREARM  377 

Fig.  183  Fig.  184 


Fig.  183. — Fracture  of  lower  end  of  radius,  differing  from  preceding  Colles'  types  in  direction  of 
line.  Accompanied  by  wide  separation  of  styloid  of  ulna.  Male,  aged  twenty-six  years.  Antero- 
posterior view,  shows  marked  displacement  to  radial  side,  and  shortening. 

Fig.  184. — Comminuted  Colles'  fracture,  with  separation  of  styloid  of  ulna  in  two  fragments, 
in  a  male,  aged  thirty-three  years.  Fragments  of  comminuted  lower  main  fragment  driven  apart 
by  entering  wedge  of  shaft,  with  widening  of  joint.  Anteroposterior  view.  Clinical  diagnosis  of 
fracture  easy,  but  x-ray  very  important  to  determine  nature  of  injury  and  deformity. 


Fig.  185 


Fig.  186 


Fig.  187 


Fig.  185. — Comminuted  Colles'  fracture  (into  joint)  with  fracture  through  neck  of  ulna,  in  adult 
female.  Anteroposterior  view  shows  good  apposition  after  reduction.  (Lateral  shows  persistence 
of  dorsal  displacement  lower  radial  fragment.)  Clinical  diagnosis  easy,  object  of  x-rays  to  deter- 
mine result  of  reduction. 

Figs.  186  and  187. — Fracture  radius  (above  level  of  Colles')  and  neck  of  ulna,  in  a  boy,  aged  .seven 
years.  (More  common  level  for  radial  fractures  in  children  than  lower  down  as  in  adults.)  Antero- 
posterior view,  Fig.  186  (before  reduction),  shows  radial  fragments  in  good  position  apparently, 
but  head  of  ulna  displaced  upward  and  to  ulnar  side.  Lateral  view.  Fig.  187,  shows  angular  defor- 
mity in  radius  (toward  palmar  aspect)  and  bad  displacement  of  ulnar  head  backward  and  upward. 
Clinical  diagnosis  of  fracture  not  diflScult,  but  x-rays  important  to  reveal  deformities. 


378 


THE  UPPER  EXTREMITY 
Fig.  188  Fig.  189 


Figs.  188  and  189. — Fracture  of  both  bones  of  forearm  in  lower  portions  of  shafts,  in  a  boy,  aged 
fourteen  years.  (Transverse  and  same  level.)  Very  common  type  of  fracture  in  children.  Tip 
of  styloid  of  ulna  separated  in  addition.  Anteroposterior  view,  Fig.  188,  indicates  slight  lateral 
displacement  both  lower  fragments  to  ulnar  side.  Lateral  view,  Fig.  189,  shows  complete  dorsal 
displacement  both  lower  fragments,  with  over-riding.  Clinical  diagnosis  of  fracture  easy,  but  im- 
portance of  x-rays  obvious. 


Fig.  190 


Fig.  191 


Figs.  190  and  191. — Fracture  both  bones  lower  portions  of  shafts,  in  a  boy,  aged  fourteen  years. 
(Transverse  and  same  level;  radius  compound.)  Anteroposterior  view,  Fig.  190,  shows  lateral 
displacement  of  both  lower  fragments  to  radial  side.  Lateral  view.  Fig.  191,  shows  displacement 
of  both  toward  palmar  aspect,  complete  in  radius.  (Exactly  opposite  displacements  from  preced- 
ing case.) 


THE  FOREARM 

Fig.  192 


379 


Old  fracture  of  both  bones,  similar  in  type  to  the  two  preceding  cases,  in  a  male,  aged  twenty- 
four  years.  Radius  imited  in  bad  position;  ulna  ununited,  lower  fragment  completely  displaced 
laterally  to  ulnar  side.  Anteroposterior  view.  (Lateral  view  shows  dorsal  displacement  of  both 
lower  fragments.) 

Fissured  fracture  of  the  lower  extremity  of  the  radius  is  attended 
by  a  tenosynovitis  similarly  placed  but  not  giving  crepitation  because 
of  a  more  abundant  effusion. 

Wounds  of  the  Forearm. — Wounds  of  the  forearm  call  for  determina- 
tion of  cutaneous  sensibility  and  power  of  free  motion  in  the  hand  and 
wrist. 

Injury  of  the  median  nerve  just  above  the  wrist,  usually  associated 
with  division  of  the  flexor  sublimis  and  palmaris  longus,  causes  a  sen- 
sory palsy  of  the  palmar  surface  of  the  thumb,  index  and  middle  fingers, 
and  radial  side  of  the  ring  finger.  Wounds  higher  up  paralyze  flexion 
at  the  second  joints  of  all  the  fingers  and  the  terminal  joints  of  the 
index  and  middle  fingers.  If  the  wound  be  near  the  elbow,  the  power 
of  pronation  is  lost. 

Injury  of  the  ulnar  nerve  paralyzes  flexion  of  the  ring  and  middle 
fingers,  adduction  of  the  thumb,  and  abduction  of  all  the  fingers;  also 
flexion  of  the  first  joint  and  extension  of  the  other  joints.  There  is 
anesthesia  of  the  ulnar  side  of  the  hand,  of  the  little  finger,  and  the 
ulnar  border  of  the  ring  finger. 

Injury  of  the  posterior  interosseous  nerve  is  characterized  by  par- 
alysis of  the  extensor  muscles,  resulting  in  wrist  drop,  more  or  less 
complete  in  proportion  to  the  height  of  the  injury. 

Fractures  of  the  Forearm, — CoUes'  fracture,  the  commonest  injury, 
is  discussed  under  affections  of  the  hand  and  wrist.  Fractures  of 
the  head  and  neck  of  the  radius,  of  the  olecranon,  and  of  the  coracoid 


380 


THE  UPPER  EXTREMITY 


process  are  considered  in  the  section  dealing  with  surgical  affections 
of  the  region  of  the  elbow. 

Fracture  of  both  hones  of  the  forearm,  in  children  often  of  the  incom- 
plete or  green-stick  variety,  is  usually  placed  below  the  middle,  and  is 
due  to  a  fall  upon  the  hand.  The  usual  cause  of  complete  fracture  of 
both  bones  is  direct  violence.  The  break  in  both  bones  is  at  or  near 
the  same  level. 

The  symptoms  in  the  case  of  green-stick  fracture  are  obvious  deformity, 
sharply  localized  tenderness  and  pain;  in  children  there  is  sometimes 
surprisingly  slight  disability. 

The  complete  fracture  is  characterized  by  crepitus,  preternatural 
mobility  and  deformity.     Non-union  is  an  occasional  sequel. 

Fracture  of  the  ulna,  if  occurring  alone,  is  usually  due  to  direct  force. 
A  break  in  the  upper  third  of  the  bone  is  not  an  uncommon  compli- 
cation of  luxation  of  the  radius.  Because  of  its  subcutaneous  posi- 
tion throughout,  fracture  of  the  ulna  is  readily  detected  by  palpation. 

Fractures  of  the  shaft  of  the  radius  are  usually  in  the  middle  third, 


Fig.  1931 


Fig.   194 


Figs.  193  and  194. — Fracture  of  both  bones  in  upper  third  of  shafts,  in  a  child,  aged  five  years, 
result  of  fall  on  hand.  Radiographs  three  weeks  after  injury  show  union  well  advanced,  with  con- 
siderable angular  deformity  in  ulna  laterally  to  radial  side.  Injury  neither  diagnosticated  nor 
treated  as  a  fracture,  although  typical  signs  must  have  been  present.  Fig.  193,  anteroposterior 
view  at  elbow;  Fig.  194,  lateral. 


1  Figs.  193  to  211. — Fractures  of  the  shafts  of  both  bones  of  the  forearm.  Outline  drawings 
from  radiographs  by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray  Laboratory; 
patients  referred  by  or  from  services  of  Drs.  White,  Wood,  and  Frazier,  from  dispensaries,  and 
private  cases  of  Dr.  Pancoast. 


THE  FOREARM 

Frc.  195  Fig.  196 


381 


Fig.  195. — Fracture  of  both  bones  near  junction  of  upper  and  middle  thirds  of  shafts,  in  male, 
aged  twenty  years,  result  of  fall  from  horizontal  bar  in  gymnasium.  Lateral  -^aew  (at  elbow, 
pronation)  before  reduction,  shows  angular  deformity  and  complete  lateral  and  forward  displace- 
ment of  upper  ulnar  fragment  with  over-riding.     Clinical  diagnosis  not  difficult. 

Fig.  196. — Fracture  of  both  bones  at  junction  of  upper  and  middle  thirds  of  shafts,  in  female, 
aged  thirty-seven  years,  transverse,  same  level.  Anteroposterior  view  before  reduction  shows 
complete  lateral  displacement  with  over-riding. 


382  THE  UPPER  EXTREMITY 

Fig.  197  Fig.  198 


Fig.  197. — Lateral  view  of  case  shown  in  Fig.  196,  after  fluoroscopic  reduction.  (Fore  and  aft 
also  shows  perfect  reduction.) 

Fig.  198. — Same  -view  of  same  case  six  weeks  later,  showing  delayed  but  moderately  firm  union 
with  marked  angular  deformity,  for  which  the  dressing,  an  anterior  rectangular  splint,  may  have 
been  wholly  or  in  part  responsible.  An  illustration  of  the  advisability  of  x-ray  examinations  during 
treatment  of  some  fractures  to  determine  proper  maintenance  of  reduction. 


and  result  from  direct  or  indirect  violence.  The  fracture  is  usually 
transverse  or  slightly  oblique.  It  may  be  spiral.  Its  detection  is 
based  upon  the  classical  symptoms,  the  local  swelling  and  tenderness, 
and  the  failure  of  the  radial  head  to  rotate  when  the  hand  is  alternately 
pronated  and  supinated. 

Inflammatory  Affections  of  the  Forearm. — Lym'phangitis  of  the 
forearm,  expressed  in  the  form  of  a  rose-colored,  slightly  raised  band 
passing  upward  to  the  elbow  along  the  course  of  the  lymphatics,  is 
symptomatic  of  infection  of  the  hand. 

Cellulitis. — Cellulitis  is  secondary  to  trauma  or  is  an  upward  exten- 
sion of  palmar  abscess.  The  pus  is  found  not  only  in  the  superficial 
and  subaponeurotic  tissue,  but  when  it  travels  along  the  tendon  sheaths 
accumulates  beneath  the  deep  flexors. 


THE  FOREARM 
Fig.  199  Fig.  200  Fig.  201 


383 


Fig.  202 


Oi 


Figs.  199  and  200. — Fracture  of  both  bones  about  middle  of  shafts,  in  a  young  boy.  Clinical 
diagnosis  of  fracture  not  difficult,  but  examination  made  ten  days  after  injury  to  determine 
position  of  fragments.  Fig.  199,  anteroposterior  view,  shows  central  displacement  with  complete 
obliteration  of  interosseous  space.  Lateral  \-iew.  Fig.  200,  indicates  palmar  and  dorsal  displace- 
ment of  lower  fragments  in  addition.  Examination  made  barely  in  time  to  anticipate  callus 
formation. 

Fig.  201. — Fracture  of  both  bones  at  junction  of  middle  and  upper  thirds,  in  a  boy,  aged 
thirteen  years;  ulna  slightly  comminuted  and  radius  "subperiosteal"  and  nearly  "green-stick." 
Detachment  of  styloid  process  of  ulna.  Injury  resulted  from  a  fall.  Clinical  diagnosis  not  diffi- 
cult, although  radial  fracture  might  escape  notice.     Anteroposterior  xaew. 

Fig.  202. — Fracture  in  a  girl,  aged  ten  years;  radius  at  junction  of  upper  and  middle  thirds 
and  "subperiosteal;"  ulna  lower  and  middle  thirds  and  "green-stick."  Anteroposterior  \-iew. 
Clinical  diagnosis  somewhat  difficult,  especially  of  ulnar  fracture. 


Osteomyelitis. — Osteomyelitis  (rare)  is  attended  with  the  characteristic 
intense  pain,  total  disability,  and  pronounced  local  and  general  symp- 
toms of  pus  formation  and  septic  absorption. 

Syphilis. — The  chronic  ulcerative  lesions  of  syphilis  are  not  infrequently 
found  on  the  skin  of  the  forearm,  and  chancre  has  been  observed  here 
sufficiently  often  to  make  it  a  diagnostic  possibility  in  the  presence  of 
a  superficial  indolent  ulceration  without  obvious  cause,  w^hich  in  the 
course  of  two  or  three  weeks  reaches  the  size  of  a  half-dollar,  and  which 


384 


THE  UPPER  EXTREMITY 
FcG.  203  Yia.  204 


Fig.  203. — Fracture  of  both  bones  in  middle  third  of  shafts,  in  a  boy,  aged  fifteen  years;  radius 
at  higher  level.  Anteroposterior  view,  before  reduction,  shows  complete  lateral  displacement  of 
ulna  and  almost  complete  of  radius,  to  radial  side.  Clinical  diagnosis  not  difficult.  (Lateral  view 
shows  no  deformity.) 

Fig.  204. — Typical  example  of  "green-stick"  fracture  of  both  bones,  at  middle  of  shafts,  in  a 
child,  aged  three  years.     Clinical  diagnosis  difficult.     Anteroposterior  view;  no  deformity. 

is  attended  with  characteristic  glandular  enlargement.  The  early  diag- 
nosis is  based  upon  the  findings  of  the  spirochete. 

Tuberculous  and  syphilitic  involvement  of  the  muscles  and  bones 
of  the  forearm  do  not  depart  from  type.  Gumma  of  the  ulna  is 
fairly  frequent,  appearing  as  a  palpable,  moderately  sensitive  node.  The 
diagnosis  is  based  upon  the  history  and  the  result  of  treatment. 

Tumors  of  the  Forearm. — Lipcmia  may  be  either  subcutaneous  or 
subaponeurotic.  In  the  latter  case  it  may  extensively  infiltrate  the 
cellular  spaces  between  the  muscles.  The  slow  growth  (years)  and 
soft,  almost  fluctuating,  consistency  are  characteristic. 

Neurofibromata  and  angiomata  are  fairly  common  on  the  forearm, 
and  enchondromata  have  been  observed. 

Sarcoma  has  its  seats  of  predilection  near  the  ends  of  the  bones.  It 
may  be  spindle-cell  or  giant-cell  or  mixed. 

The  diagnosis  in  the  early  stage  cannot  be  made  from  syphilis  or 
tuberculosis.     It  will  be  suggested  by  absence  of  syphilitic  history  or  of 


Fig.  205 


THE  FOREARM 

Fig.  20G 


385 


Fig.  207 


Figs.  205  and  206. — "Subperiosteal"  fracture  of  both  bones  near  junction  of  lower  and  middle 
third  of  shafts,  transverse  and  same  level,  in  a  boy,  aged  four  years.  Result  of  a  fall  down  stairs. 
Anteroposterior  view.  Fig.  205,  shows  lateral  angular  deformity,  and  Fig.  206,  lateral  \dew,  indi- 
cates a  decided  bend  toward  the  palmar  aspect.  Examination  before  reduction.  Clinical  diagnosis 
not  difEcult,  especially  in  view  of  deformity. 

Fig.  207. — Fracture  of  both  bones,  in  adult  male,  radius  transverse,  lower  and  middle  thirds; 
ulna  longitudinal,  through  middle  third  of  shaft.  (Compound.)  In  addition  a  fracture  of  base 
and  of  tip  of  styloid  process  of  ulna.  Satisfactory  reduction  impossible  without  operation.  Antero- 
posterior view. 


tuberculous  heredity  or  lesions  elsewhere.  In  the  absence  of  a  syphilitic 
history,  a  fixed,  persistent  bone  pain,  associated  with  tumor  which  does 
not  involve  the  nearest  joint,  is  suflBcient  cause  for  exploratory  opera- 
tion. Even  before  the  development  of  a  palpable  tumor  the  a;-rays 
may  show  the  seat  of  lesion  if  not  its  nature. 
25 


386 


THE  UPPER  EXTREMITY 


Fig.  208 


Fig.  209 


Figs.  208  and  209. — Fracture  of  both  bones  in  lower  and  middle  fourths  of  shafts,  same  level,  in 
a  male,  aged  thirty-five  years.  Anteroposterior  view.  Fig.  208,  shows  complete  lateral  displacement 
of  both  lower  fragments  to  radial  side,  with  over-riding.  Lateral  view.  Fig.  209,  shows  displace- 
ment of  upper  ends  of  lower  fragments  to  palmar  aspect.  Clinical  diagnosis  not  diflBcult,  but 
a;-rays  of  great  assistance  in  reduction. 


THE  ELBOW. 


The  two  epicondyles  can  easily  be  palpated,  even  when  there  is  great 
swelling;  the  inner  in  its  direction  indicates  the  facing  of  the  articular 
surface  of  the  upper  extremity  of  the  humerus.  Because  of  an  obliquity 
of  the  joint,  there  is  an  outward  bend  (carrying  angle)  at  the  elbow, 
perceptible  only  when  the  arm  is  extended,  and  more  marked  in  women 
than  in  men. 

The  olecranon  forms  the  bony  projection  at  the  back  of  the  elbow. 
To  either  side  of  it  the  joint  capsule  approaches  the  surface  and  here 
and  above  the  head  of  the  radius  joint  tenderness  and  effusion  are 
earliest  detected  by  palpation.  A  finger's  breadth  below  the  external 
epicondyle  the  head  of  the  radius  may  be  felt. 


THE  ELBOW 


387 


Fig.  210 


Fig.  211 


Fig.  210. — Fracture  of  both  bones  near  lower  end  of  shafts,  "subperiosteal,"  transverse,  same 
level,  in  a  boy,  aged  fifteen  years.  Caused  by  direct  violence — struck  by  automobile  crank. 
Clinical  diagnosis  not  difficult.     Anteroposterior  "view. 

Fig.  211. — Secondary  fracture  of  both  bones  in  same  case  as  Fig.  210,  occurring  fifteen  -weeks 
later,  as  a  result  of  indirect  violence.  The  lines  of  fracture  are  immediately  above  those  of  the  first 
injury.     (Plate  reversed  in  drawing.) 


With  the  forearm  extended,  the  tip  of  the  olecranon  and  the  epicon- 
dyles  are  supposed  to  lie  very  nearly  in  a  plane  with  which  the  long 
axis  of  the  humerus  makes  a  right  angle. 

Fig.  2121 


Old  fracture  of  shaft  of  ulna,  upper  and  middle  thirds,  in  an  adult  female,  imunited. 
Lateral  \-iew  at  elbow;  anteroposterior  of  forearm. 


1  Figs.  212  to  219.  Fractures  of  the  shaft  of  the  ulna.  Outline  drawings  from  radiographs  by 
Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  i-ray  Laboratorj-;  patients  referred  from 
service  of  Dr.  Martin,  from  dispensaries,  and  private  cases  of  Dr.  Pancoast. 


388 


THE   UPPER  EXTREMITY 


Fig.  213 


"Subperiosteal"  fracture  of  upper  and  middle  thirds  of  shaft  of  ulna,  in  an  adult  male,  resulting 
from  direct  violence — a  blow  on  back  of  extended  elbow  during  a  game  of  football.  Not  diag- 
nosticated clinically;  cardinal  signs  of  fracture  absent,  and  attention  drawn  mainly  to  the  more 
severe  subjective  manifestations  of  sprain  of  elbow.     Lateral  view  at  elbow. 


Fig.  214 


Fig.  215 


Figs.  214  and  215. — "Green-stick"  fracture  of  middle  of  shaft  of  ulna,  in  a  child,  aged  three 
and  one-half  years.  Not  diagnosticated  clinically,  but  examined  because  of  local  tenderness.  Fig. 
214,  anteroposterior,  and  Fig.  215,  lateral  view. 


THE  ELBOW 


389 


Fig.  216 


KiG   217 


Figs.  216  and  217. — Compound  comminuted  fracture  of  middle  third  of  shaft  of  ulna,  in  a  male, 
1  twenty-nine  years.  Fig.  216,  anteroposterior  view,  shows  only  a  part  of  the  fracture,  while  the 
lateral  view.  Fig.  217,  shows  a  much  more  extensive  break.  Clinical  diagnosis  of  injury  not  difficult, 
but  x-rays  essential  to  determine  proper  reduction. 


Flexion  and  extension  are  the  only  normal  movements  expressed 
at  the  humero-ulnar  joint.  The  humeroradio-ulnar  articulation  per- 
mits rotation  of  the  forearm. 

Normal  flexion  can  be  carried  to  the  degree  which  permits  the 
fingers  to  palpate  the  acromial  process  on  the  same  side.  Normal 
extension  brings  the  anterior  surface  of  the  arm  and  forearm  in  the 
same  plane  with  a  slight  outward  angle  (carrying  angle)  at  the  elbow. 
Rotation  of  the  forearm  can  be  carried  through  a  half  circle,  the  palm 
being  made  to  face  directly  upward  or  downward  without  movement 
at  the  shoulder. 

After  trauma,  great  swelling,  pronounced  disability,  and  intra-articular 
effusion  are  presumptive  evidence  of  fracture  or  luxation. 

Inflammation  of  the  joint  causes  limitation  of  motion  in  all  directions 
and  muscular  spasm  and  atrophy. 

Deformities  of  the  Elbow. — Congenital  luxations  have  been  noted 
either  of  both  bones  or  of  the  radius  alone.     Cubitus  valgus  and  varus 


390 


THE  UPPER  EXTREMITY 


Fig.  218 


Fig.  219 


Fig.  218.- — Fracture  at  junction  of  lower  and  middle  fourths  of  shaft  of  ulna — in  an  adult  male. 
Anteroposterior  view,  showing  complete  lateral  displacement.  (Lateral  view  indicates  none.) 
Clinical  diagnosis  of  fracture  and  deformity  easy. 

Fig.  219. — Oblique  fracture  at  lower  end  of  shaft,  or  neck,  of  ulna,  in  a  male,  aged  fifty-nine  years. 
Anteroposterior  view. 

are  descriptive  of  lateral  deviations  of  the  forearm  upon  the  arm,  valgus 
involving  abduction  (radial  side)  and  varus  adduction  (ulnar  side). 

A  similar  acquired  deformity  may  be  due  to  a  condyloid  fracture  with 
upward  displacement;  or  it  may  be  an  expression  of  rickets.  A  slight 
degree  of  valgus  is  normal. 

Contractures  of  the  elbow-joint  may  be  cicatricial  or  myogenic, 
usually  of  the  flexors.  Aside  from  those  incident  to  central  or  peripheral 
nerve  lesions,  the  commonest  cause  of  muscular  contracture  is  syphilitic 
myositis  of  the  biceps. 

Distortions  of  the  elbow-joint  are  due  to  chronic  osteoarthritis,  which 
may  be  secondary  to  trauma,  infection,  autotoxemia,  or  arteriosclerosis, 
or  may  be  of  neuropathic  origin  (tabes,  syringomyelia). 

Ankylosis  of  the  elbow-joint  is  secondary  to  traumatism  or  arthritis 
in  any  of  its  varieties.  Pyogenic  and  gonococcal  arthritis  are  the  forms 
most  likely  to  be  followed  by  complete  ankylosis. 

Limitation  of  motion  may  be  partial  or  complete,  may  involve  the 
motions  of  flexion  and  extension,  or  may  be  limited  to  the  upper  radio- 
ulnar articulation,  interfering  with  pronation  and  supination. 

Traumatism  of  the  Elbow. — Wounds. — Wounds  in  the  region  of 
the  elbow  may  involve  the  soft  parts  alone  or  may  enter  the  joint.  In  the 
first  case  examination  must  be  made  to  exclude  the  anesthesia  and  loss 


THE  ELBOW 


391 


of  motion  which  characterize  lesions  of  the  median,  musculospiral,  and 
ulnar  nerves. 

Wounds  involving  the  joint  may  be  obvious,  or,  in  case  of  puncture, 
may  be  difficult  of  immediate  detection.  If  such  wounds  are  infected 
there  is  a  prompt  synovial  effusion  characterized  by  a  fluctuating  swelling 
most  marked  posteriorly  to  either  side  of  the  olecranon  and  triceps  tendon 
and  in  the  interval  between  the  external  condyle  and  the  head  of  the 
radius;  accompanied  by  great  tenderness,  severe  pain  aggravated  by  all 
motions  of  the  joint,  and  fixation  in  a  position  of  slight  flexion.  The 
constitutional  symptoms  of  septic  absorption  develop  promptly  and  the 
overlying  skin  becomes  edematous,  hot,  and  red. 

A  moderate  aseptic  efl^usion  may  accompany  a  wound  of  the  joint 
capsule,  but  not  reaching  the  joint  itself.     The  distinction  between  this 


Fig.  220' 


Fig.  221 


Fig.  220. — Fracture  at  junction  of  upper  and  middle  thirds,  and  above  insertion  of  pronator 
radii  teres,  in  a  male,  aged  twenty-three  years.  Anteroposterior  view,  showing  typical  lateral  dis- 
placement, persisting  after  attempted  reduction.  Clinical  diagnosis  not  difEcult,  but  x-rays  essential 
for  proper  reduction.  (Fluoroscope  often  a  valuable  aid  in  reduction  of  this  particular  fracture.) 
No  anteroposterior  deformity  shown  in  lateral  view. 

Fig.  221. — Fracture  at  junction  of  middle  and  lower  thirds  of  shaft,  in  a  male,  aged  twenty-five 
years.  Anteroposterior  view  shows  slight  comminution  and  perfect  reduction.  Clinical  diagnosis 
not  difficult.  There  is  in  addition  a  fracture  of  the  tip  of  the  styloid  process  of  the  ulna,  which 
frequently  accompanies  forearm  fractures,  but  is  usually  not  recognized. 


I  Figs.  220  to  223.  Fractures  of  the  shaft  of  the  radius.  Outline  drawings  from  radiographs 
by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray  Laboratory;  patients  referred 
from  service  of  Dr.  Martin  and  from  dispensaries. 


392 


THE  UPPER  EXTREMITY 


Fig.  222 


Fio.  223 


Figs.  222  and  223. — Fracture  about  middle  and  lower  fourths  of  shaft,  in  a  male,  aged  twent.v- 
six  years.  Result  of  direct  ^'iolence — struck  on  palmar  aspect  by  automobile  crank.  Antero- 
posterior view.  Fig.  222,  shows  lateral  displacement  to  ulnar  side.  Lateral  view.  Fig.  223,  shows 
complete  palmar  displacement  of  lower  fragment  with  over-riding.  Clinical  diagnosis  of  fracture 
not  difficult. 


Fi(^.  224 


Syphilitic  rupia.     Tertiary  (years)  lesions.     Duration,  months.     No  subjective  symptoms. 

Patient  feeling  well. 


THE  ELBOW  393 

effusion  and  acute  pyogenic  infection  of  the  joint  may  be  made  early 
by  aspiration  and  microscopic  and  cultural  investigation  of  the  contents 
of  the  joint. 

Fig.  225 


Tuberculous  abscess  in  lower  end  of  radius.  Localized  pain,  tenderness,  and  swelling,  but  no 
redness.  Secondary  inflammatory  effusion  in  wrist-joint.  Tuberculous  lesion  in  upper  epiphysis 
of  femur  and  in  knee-joint.     (Carnett.) 

Sprain  of  the  Elbow. — This  is  the  commonest  form  of  injury  about  the 
joint,  involving  chiefly  the  internal  lateral  ligament,  characterized  by  a 
history  of  wrench  or  twist  such  as  is  incident  to  hurling  a  ball,  followed 
immediately  or  shortly  by  disability,  pain,  tenderness,  and  swelling,  most 
marked  over  the  seat  of  subcutaneous  injury.  In  one  or  two  days 
following  the  trauma  the  skin  may  exhibit  discoloration. 

There  may  be  bleeding  into  the  joint,  causing  a  traumatic  synovitis 
with  immediate  effusion,  characterized  by  swelling  and  fluctuation  on 
either  side  of  the  triceps  and  beneath  the  external  condyle,  and  fixation 
of  the  joint  in  slight  flexion.  The  presence  of  a  joint  effusion  is  so  sug- 
gestive of  fracture  that,  when  this  is  present,  the  rc-rays  should  always 
be  used. 

Persistent  pain,  tenderness,  and  disability  following  sprain,  unless  this 
be  frequently  repeated,  or  no  opportunity  for  recovery  has  been  given, 
are  signs  which  should  suggest  an  associated  bone  lesion. 

Fractures  about  the  Elbow. — Fracture  in  the  region  of  the  elbow 
commonly  involves  the  lower  end  of  the  humerus,  at  times  the  olecranon, 
exceptionally  the  head  or  neck  of  the  radius,  and,  almost  as  a  surgical 
curiosity,  except  as  a  complication  of  backward  luxation,  the  coronoid 
process  of  the  ulna. 


394 


Fig.  2261 


THE   UPPER  EXTREMITY 

Fig.  227 


Figs.  226  and  227. — Incomplete  supracondyloid  fracture,  in  a  child,  aged  four  years.  Antero- 
posterior view,  Fig.  226,  shows  a  fissure  extending  completely  across,  a  short  distance  above  the 
epiphyseal  line.  The  epiphysis  for  the  external  condyle  is  the  only  one  in  which  ossification  has 
begun,  and  the  possibility  of  detecting  an  epiphyseal  separation  of  this  condyle  by  the  radiograph 
would  depend  upon  an  evident  alteration  in  the  position  and  relations  of  this  centre  as  compared 
with  that  of  the  opposite  elbow.  If  reduced,  the  injury  could  not  be  diagnosticated  by  the 
x-rays  unless  there  was  an  accompanying  break  in  the  bone  adjacent.  An  epiphyseal  separation 
of  the  internal  condyle  could  not  be  determined  radiographically  at  this  age.  The  lateral  view, 
Fig.  227,  shows  the  same  fissure  extending  but  about  half-way  through  from  before  backward.  The 
identity  of  the  small  process  at  the  lower  posterior  aspect  of  the  diaphysis  is  uncertain. 


Fig.  228 


Fig.  229 


Fig.  230 


Figs.  228  and  229. — Incomplete  supracondyloid  fracture,  in  a  child,  aged  six  years.  Antero- 
posterior view.  Fig.  228,  shows  a  fissure  extending  part  way  across,  but  it  is  barely  perceptible  in 
the  lateral  view,  Fig.  229.  Note  the  increase  in  size  of  the  centre  of  ossification  in  the  epiphysis 
for  the  external  condyle  and  beginning  ossification  in  that  for  the  internal.    (See  Figs.  226  and  227.) 

Fig.  230, — Complete  supracondyloid  fracture,  in  a  child,  aged  eight  years.  The  typical  deformity 
of  this  fracture  is  shown  in  the  lateral  view  here  represented,  and  which  is  the  one  necessary.  The 
fore-and-aft  view  may  not  show  even  the  fracture  in  some  instances.  The  posterior  displacement 
is  of  a  moderate  degree.  Clinical  diagnosis  of  fracture  not  difficult,  but  in  presence  of  great  amount 
of  swelling  might  be  mistaken  for  dislocation.  Radiograph  especially  valuable  for  determining 
displacement. 


I  Figs.  226  to  234.  Supracondyloid  fractures  of  the  humerus.  Outline  drawings  from  radio- 
graphs by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray  Laboratory;  patients 
referred  from  services  of  Drs.  Martin,  Camett,  and  Wood,  from  dispensaries,  and  private  cases  of 
Dr.  Pancoast. 


THE  ELBOW 


395 


Fig.  231 


Fig.  232 


Figs.  231  and  232.— Supracondyloid  fracture,  in  a  child,  aged  nine  years.  Lateral  view.  Fig. 
231  shows  the  typical  posterior  deformity,  but  the  anteroposterior  view.  Fig.  232,  indicates  in  addi- 
tion a  very  unusual  lateral  displacement  to  the  radial  side.  The  smooth  appearance  of  the  upper 
edge  of  the  lower  fragment  gives  somewhat  the  impression  of  an  epiphyseal  separation,  but  is  due 
to  the  articular  surface  showing  above  in  place  of  broken  surface  because  of  the  peculiar  angle 
at  which  the  part  was  exposed  on  account  of  the  dressing  on  an  internal  rectangular  splint.  This 
is  a  proof  of  the  necessity  of  examining  in  both  directions,  even  under  such  difficulties  as  men- 
tioned.    Note  beginning  ossification  of  epiphysis  for  olecranon  in  Fig.  231. 


Fig.  233 


Fig.  234 


Fig.  233. — Supracondyloid  fracture  in  a  child,  aged  eight  years.  Lateral  view  before  reduction 
shows  an  extreme  degree  of  posterior  displacement  of  lower  fragment,  as  compared  with  Fig.  230. 

Fig.  234. — Supracondyloid  fracture,  in  a  male,  aged  sixty  years,  old  and  ununited.  Clinical 
diagnosis  of  injury  somewhat  diflBcult  at  this  time,  but  x-rays  show  its  exact  nature,  amount  of 
callus  and  the  deformity.     This  fracture  is  not  nearly  so  common  in  adults  as  in  children. 

Fractures  of  the  lower  end  of  the  humerus  may  be  supracondyloid, 
intercondyloid,  condyloid,  epicondyloid,  or  epiphyseal.  All  these  frac- 
tures, except  the  sypracondyloid  and  epicondyloid,  involve  the  elbow- 
joint,  and  are  accompanied  by  almost  immediate  and  pronounced 
swelling  due  at  first  to  blood  effusion  into  and  around  the  joint,  later  to 


396 


THE  UPPER  EXTREMITY 


traumatic  inflammatory  reaction.  The  rapid  and  extensive  swelling 
is  in  itself  presumptive  evidence  of  the  presence  of  fracture  as  opposed 
to  sprain. 

Swpracondyloid  fracture,  common  in  children  under  ten  years  of  age, 
follows  a  fall  on  the  bent  elbow  or  the  outstretched  hand.  It  is  usually 
oblique  from  below  upward  and  from  in  front  backward.  Hence  the 
lower  end  of  the  upper  fragment  projects  anteriorly  and  occasionally 
injures  the  bloodvessels  or  nerves.  When  the  injury  is  due  to  a  fall 
upon  the  bent  elbow  (adults)  the  line  of  fracture  may  be  oblique  from 
in  front  downward  and  backward.  Hence,  the  lower  end  of  the  upper 
fragment  projects  backward,  the  lower  fragment  lying  forward  and 
usually  inward. 

Rapid  extra-articular  swelling,  the  preservation  of  the  normal  relation 
of  the  tip  of  the  olecranon,  the  head  of  the  radius,  and  the  internal  and 


Fig.  2351 


Fig.  236 


Fig.  235. — Fracture  of  both  condyles,  in  male,  aged  fifty-four  years,  resulting  from  a  fall  out  of 
a  window.  Wide  separation  of  fragments.  Clinical  diagnosis  not  difficult,  except  as  obscured  by 
great  swelling.  Exact  nature  of  injury  more  readily  determined  by  radiograph,  which  also  shows 
exact  deformity.  Anteroposterior  view  represented,  and  is  the  more  important  one,  although 
difficult  to  obtain  on  account  of  flexion  of  forearm.  (Latter  accounts  for  distortion  of  bones  of 
forearm.) 

Fig.  236. — Fracture  of  both  condyles,  in  a  girl,  aged  thirteen  years,  with  lateral  separation  and 
upward  displacement  of  fragments.  The  smooth  upper  surfaces  of  the  fragments  suggests  a  separa- 
tion of  the  lower  epiphysis  (the  two  condylar  epiphyseal  centres  being  fused  at  this  age),  but  the 
portion  of  the  shaft  attached  to  the  internal  condylar  fragment  indicates  that  the  epiphysis  has 
united  on  the  inner  side  at  least.  The  patient's  age  being  that  at  which  this  epiphysis  begins 
to  unite,  the  injury  is  probably  both  a  fracture  and  an  epiphyseal  separation  above  the  condyles, 
and  a  fracture  between  them.  The  centre  for  the  internal  epicondyle  has  not  yet  united.  Clinical 
diagnosis  of  injury  not  difficult,  but  radiographs  essential  to  determine  displacement.  Proper 
reduction  was  impossible  without  operation. 

1  Figs.  235  and  236.  Fractures  at  the  lower  end  of  the  humerus — both  condylen.  Outline 
drawings  from  radiographs  by  Dr.  H.  K.  Pancoast  in  collection  of  the  University  Hospital  x-ray 
Laboratory;  patients  referred  from  services  of  Drs.  White  and  Martin. 


THE  ELBOW 


397 


external  condyle,  estimated  by  comparison  with  the  uninjured  side, 
crepitus  and  preternatural  mobility  above  the  condyles  elicited  by 
grasping  the  elbow  and  rocking  it  from  side  to  side,  limited  flexion  and 
exaggerated  extension,  deformity  obvious  on  both  palpation  and  inspec- 
tion, and  shortening  as  measured  from  the  acromion  to  the  external 
epicondyle,  make  the  diagnosis  easy. 

Condyloid  fracture  may  be  of  either  the  internal  or  the  external  condyle. 

Fractures  of  the  external  condyle,  especially  frequent  in  children, 
involve  the  capitellum,  sometimes  the  trochlea.  They  are  characterized 
by  swelling,  pain,  and  tenderness,  which  reach  their  maximum  intensity 


Fig.  23-1 


Fig.  238 


Fig.  237. — Fracture  of  the  external  condyle 
in  a  child,  aged  four  years,  the  line  of  fracture 
appearing  as  a  fissure  immediately  above  the 
epiphyseal  line,  and  extending  into  it.  Shows  in 
anteroposterior  view  only.  Clinical  diagnosis 
difficult — depending  mainly  upon  pain  on  motion 
and  local  tenderness.  (No  displacement,  and 
crepitus  and  preternatural  mobility  absent.) 

Fig.  238. — Normal  elbow  of  the  same  case  as 
Fig.  237,  and  same  view  (anteroposterior). 


Fig.  240 


Figs.  239  and  240. — Fracture  external  condyle, 
in  a  boy,  aged  five  years,  at  a  higher  level  than  the 
preceding,  and  with  slight  downward  and  outward 
displacement,  latter  shown  in  anteroposterior 
view.  Fig.  239.  (Lateral  view,  Fig.  240.)  Clin- 
ical diagnosis  not  so  diflBcult  as  in  preceding  case, 
deformity  and  crepitus   being   determinable. 


'  Figs.  237  to  247.  Fractures  of  the  lower  end  of  the  humerus — external  condyle.  Outline 
drawings  from  radiographs  by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray 
Laboratory;  patients  referred  from  service  of  Dr.  Frazier,  from  dispensaries,  and  private  cases  of 
Dr.  Pancoast, 


398 


Fig.  241 


THE   UPPER  EXTREMITY 

Fig.  242 


Figs.  241  and  242. — Fracture  of  the  external  condyle  in  a  boy,  aged  ten  years,  the  line  of  fracture 
appearing  as  a  fissure  just  above  the  epiphyseal  line,  and  tending  almost  to  an  incomplete  fracture 
of  the  internal  condyle  as  well  (or  there  may  have  been  a  separation  of  the  unossified  epiphysis) 
without  displacement.  Both  this  case  and  Fig.  237  might  be  regarded  as  epiphyseal  separations. 
In  the  absence  of  displacement  the  clinical  diagnosis  is  difficult,  crepitus  being  absent  or  ill-defined. 
Fig.  241,  anteroposterior,  and  Fig.  242,  lateral  ^dew. 


Fig.  243 


Fig.  244 


Figs.  243  and  244. — Peculiar  fracture  of  external  condyle — separation  of  anterior  portion  of 
articular  surface  of  capitellum,  in  a  female,  aged  forty-five  years.  Upward  and  forward  displace- 
ment of  fragment.  Clinical  diagnosis  difficult,  deformity  not  in  evidence,  preternatural  mobility 
impossible  to  determine,  and  crepitus  hard  to  locate.  Exact  diagnosis  essential  to  prevent  future 
disability,  and  readily  shown  by  radiographs.  Fig.  243,  anteroposterior  view,  and  Fig.  244,  lateral 
view. 


THE  ELBOW  399 

Fig.  245  Fig.  246 


Figs.  245  and  246. — Old  fracture  of  external  condyle,  in  a  male,  aged  twenty-one  years,  with 
more  or  less  union  of  fragment  in  peculiar  position,  the  broken  surface  having  rotated  outward, 
and  the  articular  surface  inward  nearly  90  degrees  on  anteroposterior  axis.  Very  poor  surgical 
result  from  z-ray  standpoint,  but  fairly  good  functionally.  Radiographs  made  because  of  a  recent 
injury.  (Negative.)  Fracture  and  displacement  both  shown  in  anteroposterior  view.  Fig.  245, 
but  neither  in  lateral  view.  Fig.  246. 

Fig.  247 


Fracture  of  external  condyle  and  tip  of  coronoid  process  of  ulna,  with  lateral  outward  displace- 
ment of  condylar  fragment  and  corresponding  dislocation  of  both  bones  of  forearm.  Male, 
aged  twenty-seven  years.  Clinical  diagnosis  not  difficult  unless  obscured  by  great  amount  of 
swelling.  Anteroposterior  radiograph  shows  exact  nature  of  injury  and  the  displacement  more 
readily,  however. 


400 


THE   UPPER  EXTREMITY 


over  the  external  condyle;  outward  displacement  of  the  head  of  the 
radius  which  moves  with  the  condyle,  and  usually  crepitus  and  mobility 
detected  by  direct  palpation  and  manipulation  of  the  condyle  while 
traction  is  exerted  upon  the  forearm  and  it  is  rocked  laterally. 

Fracture  of  the  internal  condyle  involves  a  part  or  the  whole  of  the 
trochlea,  often  a  part  of  the  capitellum.  It  is  evidenced  by  swelling, 
pain,  and  tenderness,  particularly  marked  in  the  region  of  the  internal 
condyle,  and  crepitus  elicited  by  direct  palpation.  Traction,  flexion, 
extension,  and  lateral  rocking  may  demonstrate  crepitus  and  preter- 
natural mobility  if  it  cannot  be  felt  by  grasping  the  condyle  and  attempt- 
ing to  move  it  in  various  directions.  There  is  usually  a  partial  back- 
ward and  inward  displacement  of  the  ulna  which  carries  the  internal 
condyle  with  it  and  which  is  easily  reduced  but  as  easily  recurs. 

Fracture  of  the  internal  epicondyle,  usually,  but  not  always,  extra- 
articular, is  marked  by  sharply  localized  pain,  tenderness,  and  swelling, 
and  the  detection  of  preternatural  mobility  and  crepitus  by  direct  palpa- 
tion.    It  is  sometimes  complicated  by  injury  of  the  ulnar  nerve. 


Fig.  2481 


Fig.  249 


Figs.  248  and  249. — Old  (thirteen  months)  ununited  fracture  of  the  internal  condyle,  in  a  male, 
aged  twenty-one  years.  The  lateral  view,  Fig.  248,  shows  the  fragment  completely  separated  and 
displaced  anteriorly,  while  the  anteroposterior  picture.  Fig.  249,  is  remarkable  in  giving  the  impres- 
sion of  a  perfectly  normal  elbow,  with  not  the  slightest  suggestion  of  a  fracture,  even  though 
details  are  clear. 


1  Figs.  248  to  2,52.  Fractures  of  the  lower  end  of  the  hiunerus — internal  condyle  and  epicondyles. 
Outline  drawings  from  radiographs  by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital 
w-ray  Laboratory;   patients  referred  from  dispensaries. 


THE  ELBOW 


401 


Fig.  250 


Fig.  251 


Figs.  250  and  251. — Fracture  of  the  internal  epicondyle,  in  a  male,  aged  eighteen  years  (being 
about  age  of  union,  may  be  epiphyseal  separation),  resulting  from  either  direct  violence  or  mus- 
cular action  during  a  ■wrestling  match.  Complete  separation  (muscular  attachments).  Fig.  250, 
anteroposterior,  and  Fig.  251,  lateral  view. 


Fig.  252 


Fracture  of  both  epicondyles,  in  a  male,  aged  twenty-four  years.    Very  slight  displacement. 
Clinical  diagnosis  not  difficult.    Anteroposterior  view.     (Lateral  -view  practically  negative.) 

26 


402 


THE  UPPER  EXTREMITY 


Supracondyloid  and  intercondyloid  fractures  are  characterized  by  a  line 
or  lines  of  break  passing  into  the  joint  in  addition  to  the  supracondyloid 
fracture.  They  are  usually  due  to  falls  upon  the  elbow,  and  are  inci- 
dent to  the  direct  splitting  force  transmitted  from  the  olecranon.  Such 
fracture  may  appear  in  the  form  of  a  T  or  a  Y,  or  may  be  greatly  com- 
minuted.    They  occur  in  the  adult  as  well  as  in  children. 

The  apparent  reduction  of  the  deformity  is  simple,  but  it  is  as  readily 
reproduced. 

Intercondyloid  fracture  is  attended  by  rapid  and  pronounced  swell- 
ing within  and  around  the  joint,  which  is  held  in  a  position  of  slight 
flexion.  On  grasping  and  attempting  to  move  the  condyles  with  the 
finger  and  thumb  of  each  hand,  preternatural  mobility  and  crepitus 
can  be  elicited,  the  condyles  moving  independently  of  each  other.  If 
the  ulna  is  driven  between  the  condyles,  the  olecranon  will  be  displaced 
upward  and  backward.  The  distinction  from  luxation  is  based  upon 
preternatural  mobility  as  opposed  to  fixation,  the  ease  of  apparent 
reduction,  and  the  prompt  reappearance  of  deformity  when  the  reduc- 
ing force  is  removed.  Also  by  bone  crepitus,  obvious  displacement 
of  the  condyles,  and  a  marked  increase  of  the  intercondyloid  measure- 
ment. Extensive  comminution  with  great  displacement  of  fragments 
is  common,  nor  can  this  be  accurately  diagnosticated  except  by  the 
x-ray. 

Fig.  2531  Fig.  254 


Fig.  253. — Fraotiire  of  extreme  tip  of  olecranon,  in  an  adult  male,  result  of  direct  violence  (struck 
by  automobile  crank).  Triceps  insertion  not  involved,  therefore  no  displacement.  Small  frag- 
ment covered  by  bursa,  and  diagnosis  difficult  on  account  of  swelling. 

Fig.  254. — Peculiar  fracture  of  olecranon  comparable  to  a  rupture  of  the  triceps  tendon.  Sepa- 
ration from  posterior  surface  of  scale-like  fragment  representing  attachment  of  the  tendon.  Wide 
separation  from  retraction  of  latter.     Adult  male. 

1  I'igs.  253  to  262.  Fractures  of  the  olecranon  and  coronoid  processes.  Outline  drawings  from 
radiographs  by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray  Laboratory;  patients 
referred  by  or  from  services  of  Drs.  Martin,  Frazier,  and  Siter,  and  from  dispensaries,  and  private 
cases  of  Dr.  Pancoast. 


THE  ELBOW 


403 


Fig.  255 


Fig.  256 


Fig.  255. — Typical  fracture  of  olecranon,  with  usual 
degree  of  separation  from  action  of  triceps,  in  a  male,  aged 
twenty-seven  years.  Clinical  diagnosis  not  difficult. 
X-rays  show  no  complicating  fracture. 

Fig.  256. — Old  "subligamentous"  fracture  of  olecra- 
non, in  adult  female,  diagnosticated  and  treated  as  rup- 
ture of  triceps  tendon.  First  radiograph,  two  years 
after  injury,  indicates  fibrous  but  no  bony  union.  Caused 
by  direct  violence — fall  from  trolley  car. 


Fig.  257 


Fig.  258 


Figs.  257  and  258. — Fracture  of  olecranon  and 
incomplete  fracture  of  external  condyle  of  hum- 
erus, in  male,  aged  forty-nine  years,  due  to  direct 
violence — fall  on  elbow.  Lateral  view,  Fig.  257, 
shows  only  fracture  of  olecranon,  without  sepa- 
ration, and  slightly  below  usual  level.  Antero- 
posterior view,  Fig.  258,  shows  only  the  fracture 
of  the  external  condyle.  Both  views  necessary 
for  complete  diagnosis.  Clinical  diagnosis  of 
condylar  fracture  difficult.  (Absence  of  de- 
formity, mobility,  and  crepitus.)  Also,  more 
conspicuous  olecranon  fracture  apt  to  detract 
attention  from  latter. 


404 


THE   UPPER  EXTREMITY 

Fig.  259 


Incomplete  longitudinal  fissured   fracture  of  olecranon  and  upper  portion  of  shaft  of  ulna, 
in  a  male,  aged  twenty-five  years,  result  of  gunshot  injury. 

Fig.  260 


Normal  elbow  of  a  boy,  aged  sixteen  years,  showing  the  epiphyseal  line  just  before  union  of 
epiphysis  of  olecranon  with  shaft,  occurring  at  this  age.  This  line  is  often  mistaken  for  fracture, 
and  a  year  or  two  later  such  an  appearance  would  imply  the  latter. 


Fig.  261 


Fig.  262 


Fig.  261. — Fracture  of  tip  of  coronoid  process  of  ulna,  in  a  male, 
aged  thirty-six  years,  resulting  from  a  fall  on  the  elbow.  (Un- 
usual.) Clinical  diagnosis  difficult,  pain  on  movement,  limitation  of 
motion,  and  local  tenderness,  but  absence  of  cardinal  signs. 

Fig.  262. — Example  of  a  '  'sprain  fracture"  at  elbow,  separation  of 
inner  edge  of  coronoid  process  representing  the  attachment  of  a 
portion  of  the  internal  lateral  ligament.  Equivalent  to  a  severe 
sprain.  Pain  and  local  tenderness  led  to  the  suspicion  of  a  fracture 
of  the  internal  condyle.     (Male,  aged  twenty-nine  years.) 


THE  ELBOW 


405 


Fractures  of  the  olecranon,  due  to  falls  on  the  elbow  or  muscular 
action,  may  be  extra-articular  in  the  form  of  a  tearing  off  of  the  bone 
attachment  of  the  triceps  tendon;  usually  they  are  intra-articular  and 
are  attended  by  an  abundant  joint  effusion.  They  are  manifested  by 
pain  and  tenderness,  most  marked  at  the  seat  of  injury,  inability  to 
extend  the  arm,  or  to  extend  it  forcibly,  pain  experienced  in  attempting 
this  motion,  separation  of  fragments  and  preternatural  mobility  detected 
by  direct  palpation.  "VMien  the  bones  are  held  in  place  by  the  invest- 
ing fibrous  tissue,  persistent  localized  tenderness,  swelling,  pain  and 
loss  of  power  on  attempting  extension  may  be  the  only  symptoms. 
The  a'-rays  may  be  needful  for  diagnosis;  also,  in  young  people,  an 
interpreter  familiar  with  epiphyseal  development. 

Fracture  of  the  coronoid  ^process  of  the  ulna,  a  common  complication 
of  backward  dislocation,  rare  as  an  isolated  lesion,  is  attended  by  imme- 
diate joint  effusion  and  persistent  tenderness  and  pain  located  in  the 
bend  of  the  elbow  to  the  inner  side  of  the  biceps  tendon.  The  diagnosis 
must  be  made  by  the  a'-rays. 

Fractures  of  the  head  and  neck  of  the  radius  due  to  a  fall  upon  the 
hand,  probably  with  the  arm  straight,  are  characterized  by  an  effusion 
into  the  entire  joint,  tenderness  most  marked  over  the  head  or  neck  of 
the  radius,  and,  if  the  fracture  be  complete  and  involve  the  neck,  failure 
of  the  head  to  follow  the  shaft  in  the  motions  of  pronation  and  supina- 


FiG.  2631 


Fig.  264 


Figs.  263  and  264. — Incomplete  longitudinal  fissured  fracture  of  head  of  radius  in  a  female,  aged 
twenty-five  years,  resulting  from  indirect  violence.  (Fall  down  stairs,  striking  on  hand.)  Antero- 
posterior view  (Fig.  263)  is  most  likely  to  show  such  a  break.  Clinical  diagnosis  difBcult,  and  this 
type  of  fracture  not  detected  in  majority  of  cases.  Only  signs,  pain  on  motion,  local  tenderness, 
and  ill-defined  '  'click"  on  rotation.  Orbicular  ligament  prevents  displacement.  Lateral  view 
( Fig.  264)  frequently  does  not  show  this  type  on  account  of  overlying  olecranon. 


1  Figs.  263  to  271.  Fractures  of  the  head  and  neck  of  radius.  Outline  drawings  from  radio- 
graphs by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  z-ray  Laboratory;  patients 
referred  by  or  from  ser\"ice  of  Dr.  Martin,  and  from  dispensaries,  and  private  cases  of  Dr.  Pancoast. 


406 


THE   UPPER  EXTREMITY 
Fig.  265 


Incomplete  longitudinal  fracture  (fissured)  of  head  of  radius,  and  either  a  fracture  or  epiphyseal 
separation  of  internal  epicondyle  of  humerus,  in  a  boy,  aged  seventeen  years.  (Very  near  age 
of  union  of  this  epiphysis.)  Diagnosis  of  latter  injury  not  difficult  clinically.  Neither  fracture 
could  be  detected  in  the  lateral  view. 

Fig.  266 


Old  (six  months)  comminuted  and  impacted  fracture  of  head  and  neck  of  radius,  united  with 
permanent  displacement  of  fragments.  Female,  aged  thirty-two  years,  referred  for  determina- 
tion of  cause  of  partial  ankylosis  of  joint.  Clinical  diagnosis  of  such  a  type  of  fracture  should 
not  have  been  difficult  at  time  of  injury. 


THE  ELBOW  407 

Fig.  267  Fig.  268 


Figs.  267  and  268. — Old  (five  weeks)  comminuted  fracture  of  head,  neck,  and  upper  portion  of 
shaft  of  radius  in  an  adult  male.  The  lateral  view,  Fig.  267,  shows  a  longitudinal  split  through  the 
head,  neck,  and  shaft,  and  a  large  fragment  of  the  head  completely  separated  and  displaced  outside 
of  the  orbicular  ligament.  Reduction  of  latter  by  manipulation  impossible.  Anteroposterior 
view,  Fig.  268,  important  and  remarkable  for  the  reason  that  it  presents  the  appearance  of  a  per- 
fectly normal  elbow.  Case  not  properly  diagnosticated  at  time  of  injury,  although  an  exact  clinical 
diagnosis  would  be  very  difficult  without  the  radiograph. 


Fig.  269 


Fig.  270 


Fig.  271 


Figs.  269  and  270. — Impacted  fracture  of  neck  of  radius,  in  a  boy,  aged  nine  years,  resulting  from 
a  fall  on  the  hand.  Clinical  diagnosis  difficult  because  of  absence  of  crepitus  and  deformity,  and 
the  fact  that  the  head  rotated  with  the  shaft.  Pain  on  rotation  and  local  tenderness  most  promi- 
nent signs.  Fracture  of  neck  and  epiphyseal  separation  of  head  are  more  common  in  children 
than  fracture  of  the  head. 

Fig.  271. — Impacted  fracture  of  neck  of  radius  and  fracture  of  bony  portion  of  olecranon,  in  a 
child,  aged  five  years.  Latter  "subligamentous,"  and  cHnical  diagnosis  not  difficult,  as  was  the 
case  with  radial  fracture.  These  two  fractures  not  uncommonly  occur  together  in  children.  Child 
too  young  for  appearance  of  ossification  in  olecranon  epiphysis,  and  like-svise  in  that  of  head  of  radius. 
Lateral  \'iew. 


408 


THE   UPPER  EXTREMITY 


tion.  Shortly  after  the  injury  these  motions  will  be  so  painful  that 
they  cannot  be  performed  actively  nor  tolerated  passively.  Crepitus 
may  be  elicited.  The  diagnosis  in  fissured  or  impacted  fractures,  and 
in  most  of  the  complete  ones  must  be  made  by  the  x-rays,  or,  in  the 
absence  of  this,  may  be  based  upon  persistent  disability  and  localized 
tenderness. 

The  diagnosis  of  all  injuries  about  the  elbow-joint  should  be  revised 
by  careful  ar-ray  pictures  interpreted,  in  the  case  of  children,  by  one 
familiar  with  epiphyseal  development  and  ossifying  centres.  The 
prognosis  in  all  these  injuries  must  be  guarded  in  so  far  as  complete 
functional  and  cosmetic  restoration  are  concerned. 

Dislocations  of  the  Elbow. — Dislocations  of  the  elbow,  usually  of  both 
bones  backward,  common  in  young  people,  are  usually  due  to  falls, 
the  weight  of  the  body  being  suddenly  arrested  by  the  outstretched 

Fig.  2721 


Unusual  form  of  injury  in  a  man,  aged  fifty-seven  years,  result  of  a  fall  either  on  hand  or 
elbow,  probably  the  former.  Definite  clinical  diagnosis  could  not  be  made.  Evidently  the  force 
exerted  through  radius  caused  more  or  less  impacted  fracture  of  external  condyle.  Force  on  ulnar 
side  probably  largely  expended  in  a  transverse  fracture  of  ulna  below  base  of  coronoid.  In  addition, 
an  incomplete  fracture  of  internal  condyle.     (Both  condyles  complete  would  constitute  "V"  type.) 


1  Figs.  272  to  284.  Dislocations,  unusual  fractures,  and  complex  injuries  at  the  elbow.  Outline 
drawings  from  radiographs  by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray 
Laboratory;  patients  referred  by  or  from  service  of  Dr.  Martin  and  from  dispensaries,  and  private 
cases  of  Dr.  Pancoast. 


THE  ELBOW 


409 


Fig.  273 


Fig.  274 


Figs.  273  and  274. — Oblique  fracture,  slightly  comminuted,  at  junction  of  head  and  neck  of  radius, 
and  a  fracture  through  the  ulna  at  base  of  coronoid  process.  Adult  female.  Exact  cause  not 
known.  Fig.  273,  lateral  view,  shows  the  fragment  of  the  head  of  the  radius  completely  de- 
tached, but  almost  entirely  obscured  by  the  olecranon.  Fig.  274,  anteroposterior  view,  shows 
the  head  displaced  upward  and  backward  behind  the  external  condyle  and  turned  with  the  articular 
surface  facing  anteriorly.  Exact  clinical  diagnosis  extremely  difl5cult,  especially  in  regard  to  the 
radial  fracture.     Radiograph  indicates  reduction  of  the  head  impossible. 


hand  with  the  elbow-joint  in  full  extension.  The  ligaments  are  usually 
torn  from  their  attachment  to  the  humerus,  the  internal  lateral  often 
carrying  its  epicondyle  with  it.  Fracture  of  the  coronoid  process  is 
also  noted. 

The  diagnosis  is  based  upon  the  relative  position  of  the  external  and 
internal  condyle  of  the  humerus  to  the  olecranon  process  and  head  of 
the  radius.  In  the  normal  joint  with  the  arm  extended,  the  tip  of  the 
olecranon  lies  very  slightly  above  a  line  drawn  transversely  across  the 
back  of  the  elbow  from  one  condyle  to  the  other.  In  backward  luxa- 
tion the  tip  of  the  olecranon  lies  well  above  this  line.  There  is  an 
elastic  resistance  to  flexion  beyond  an  obtuse  angle;  when  carried  as 
far  as  possible  the  olecranon  projects  backward  as  compared  with  the 
same  bony  process  of  the  sound  side.  Behind  the  external  condyle  the 
head  of  the  radius  can  be  felt  in  its  abnormal  position.  The  smooth, 
rounded,  articular  extremity  of  the  humerus  can  be  felt  in  front,  and 
below  the  bend  of  the  elbow.  Compared  measurements  of  the  injured 
and  the  healthy  arm  show  shortening  as  measured  from  the  condyle 


410 


THE   UPPER  EXTREMITY 


to  the  styloid  process;  absence  of  shortening  as  measured  from  the 
acromion  to  the  external  condyle. 


Fig.  275 


Fig.  276 


Figs.  275  and  276. — Complicated  elbow  injury  in  a  woman,  aged  fifty-nine  years.  Had  been 
diagnosticated  and  treated  by  her  physician  as  a  sprain.  The  radiographs  made  several  weeks 
later  show  the  following:  (a)  Unreduced  posterior  dislocation  of  both  bones;  (fo)  comminuted  frac- 
ture of  the  head  of  the  radius;  (c)  comminuted  fracture  of  the  shaft  at  about  the  biceps  insertion; 
(d)  fracture  of  she  tip  of  the  coronoid  process  of  the  ulna  (Fig.  275).  Clinically,  the  serious 
nature  of  the  injury  should  have  been  evident,  and  a  diagnosis  of  the  dislocation  and  the  lower 
radial  fracture  should  have  been  made  readily,  although  complete  diagnosis  would  have  been  prac- 
tically impossible  without  an  2;-ray  examination.     Fig.  275,  lateral  view;  Fig.  276,  anteroposterior 


Fig.  277 


Fracture  of  the  neck  of  the  radius  and  of  the  ulna  below  the  base  of  the  coronoid  process,  in  an 
adult  female,  resulting  from  a  fall  on  the  arm  and  elbow.  (Lateral  view.)  Exact  diagnosis  was 
uncertain  clinically,  but  was  readily  determined  radiographically,  and  reduction  much  simplified. 


THE  ELBOW 


411 


Fig.  278 


Fig.  279 


Figs.  278  and  279. — Unreduced  dislocation  elbow,  both  bones  posterior,  in  an  adult  female.  Clini- 
cal diagnosis  not  difficult,  but  injury  in  this  case  not  recognized  by  physician.  Caused  by  fall  from 
car.  In  Fig.  279,  anteroposterior  view,  the  appearance  of  lateral  displacement  to  radial  side  is  one 
always  observed  in  the  radiograph  in  this  direction. 


Fig.  280 


Fig.  281 


Figs.  280  and  281. — Unreduced  dislocation  of  elbow,  lateral,  both  bones  to  ulnar  side,  in  male,  aged 
twenty-three  years.  Clinical  diagnosis  of  the  dislocation  not  difficult,  but  radiograph  essential 
in  excluding  a  possible  complicating  fracture,  for  which  both  views  are  necessary,  although  the 
luxation  is  shown  in  the  fore-and-aft  one  only. 


412 


THE  UPPER  EXTREMITY 


In  supracondyloid  fracture  the  angular  projection  of  the  lower  end 
of  the  upper  fragment  is  felt  in  front  but  is  above  the  bend  of  the 
elbow;  there  is  no  resistance  aside  from  that  incident  to  pain  to  either 
flexion  or  extension;  there  is  usually  preternatural  lateral  mobility. 

Forward  luxation  of  both  hones  of  the  forearm  is  extremely  rare.  It 
is  due  to  direct  force  applied  to  the  back  of  the  flexed  elbow,  and  is  not 
infrequently  complicated  by  fracture  of  the  olecranon,  in  which  case 
the  fragment  attached  to  the  triceps  tendon  remains  in  place.  This 
dislocation  would  seem  impossible  without  such  a  fracture  or  a  rupture 
of  the  tendon  of  the  triceps. 


Fig.  282 


Fig.  283 


Fig.  284 


Fig.  282. — Unreduced  anterior  dislocation  of  head  of  radius,  in  a  child,  aged  seven  years. 
(Recent.)     Ossification  has  not  begun  in  the  epiphysis  for  the  head. 

Figs.  283  and  284. — Old,  unreduced,  posterior  dislocation  of  head  of  radius,  in  a  female,  aged 
twenty-one  years.  Not  diagnosticated  or  treated,  although  the  condition  was  easily  recognized  at 
the  time  the  radiographs  were  made.  Fig.  283,  nearly  lateral  view,  shows  ulna  in  place,  but  head 
of  radius  displaced  back  of  olecranon.  Fore-and-aft  view.  Fig.  284,  shows  it  above  and  behind 
the  articular  surface  of  the  external  condyle. 

Lateral  luxations  of  both  bones  of  the  forearm,  incomplete  to  the  inner 
side  or  complete  or  incomplete  to  the  outer  side,  are  characterized  by 
an  obvious  deformity,  the  condyle  bulging  on  one  side  and  the  displaced 
ulna  or  radius  on  the  other.  Flexion  to  or  beyond  a  right  angle  is  pos- 
sible in  these  cases  and  external  displacement  is  complicated  by  fracture 
of  the  inner  epicondyle. 

Divergent  dislocation  of  the  radius  and  ulna  may  be  anteroposterior, 
in  which  case  the  ulna  is  displaced  behind  the  articular  surface  of  the 
humerus  and  the  radius  in  front  of  it;  or  transverse,  the  ulna  being 
displaced  inward  and  the  head  of  the  radius  outward. 

Dislocation  of  the  ulna  alone  (rare)  is  characterized  by  extension 
of  the  arm  with  limitation  of  flexion  but  free  rotation.  Palpation 
shows  the  head  of  the  radius  in  place,  the  olecranon  displaced  posteriorly, 
the  trochlear  surface  of  the  humerus  forming  a  projection  in  front. 


THE  ELBOW 


413 


Dislocation  of  the  radius  is  likely  to  be  forward,  and  may  be  compli- 
cated by  fracture  of  the  ulnar  shaft.  It  may  occur  from  a  fall  on  the 
hand.  Flexion  is  limited  to  a  right  angle;  on  extending  the  arm, 
the  head  of  the  radius  is  found  lying  in  front  of  its  normal  position 
in  the  bend  at  the  elbow;  there  is  a  depression  in  its  normal  position 
below  the  condyle.  Outward  luxation  of  the  radius  (rare)  is  readily 
recognized  by  the  displaced  bone.  It  has  been  frequently  complicated 
by  fracture  involving  the  inner  articular  surface. 

Fig.  285 


Backward  luxation  of  ulna  and  radius.  Treated  originally  for  sprain.  Exhibiting  limited 
flexion  and  extension.  Shortening  of  forearm  (from  external  condyle  to  styloid  process  of  radius), 
backward  projection  of  the  olecranon,  prominence  of  the  biceps  tendon.  Accentuation  of  the  de- 
pression behind  the  external  condyle.     Backward  and  outward  displacement  of  the  head  of  the 

radius. 


Subluxation  of  the  radium  is  supposed  to  be  due  to  a  partial  displace- 
ment of  the  head  of  the  bone  from  the  orbicular  ligament.  It  is  observed 
only  in  young  children  who  have  been  lifted  or  pulled  by  the  hand  or  wrist. 
There  is  often,  but  not  always,  sudden  pain.  The  affection  is  marked  by 
disability,  the  arm  hanging  at  the  side  with  slight  flexion  at  the  elbow 
and  pronation  of  the  forearm.  The  only  point  of  tenderness  is  over 
the  head  of  the  radius.     Supination  is  limited.     The  diagnosis  is  made 


414  THE   UPPER  EXTREMITY 

by  the  readiness  with  which  the  condition  is  cured  by  traction  and 
forcible  supination. 

Inflammation  of  the  Elbow. — The  skin  overlying  the  region  of 
the  elbow,  is  subject  to  the  inflammatory  affections  observed  in  other 
parts  of  the  body.  On  the  back  of  the  elbow  the  lesions  of  psoriasis 
and  those  of  secondary  and  tertiary  syphilis  are  likely  to  be  well  marked. 
In  the  latter  case  the  eruption  is  characterized  by  its  indolence,  often 
its  symmetry,  by  its  circinate  borders,  its  history,  and  its  prompt  yielding 
to  specific  treatment. 

Acute  Circumscribed  Inflammation. — Acute  circumscribed  inflamma- 
tion, involving  the  soft  tissues  about  the  elbow-joint,  may  appear  as  a 
boil  or  carbuncle,  as  a  bursitis  or  an  adenitis. 

Acute  Bursitis. — ^The  bursa  commonly  involved  is  that  lying  between 
the  olecranon  and  the  skin.  The  affection  is  usually  traumatic,  often 
accompanied  by  a  wound.  It  is  marked  by  heat,  redness,  swelling, 
fluctuation,  and  often  fine  crepitation  from  blood  effusion.  If  pus  forms, 
the  local  inflammatory  symptoms  are  rapidly  progressive  and  are  asso- 
ciated with  general  symptoms  of  septic  absorption.  The  diagnosis  is 
based  on  the  seat  of  the  inflammation  which  is  distinctly  subdermal, 
fluctuation  from  the  first,  and  absence  of  joint  involvement. 

Chronic  bursitis,  which  may  be  traumatic  or  a  local  expression  of 
toxemia  or  infection,  is  characterized  by  the  rapid  or  slow  formation 
of  a  usually  fluctuating  tumor  in  the  position  of  the  olecranon  bursa. 

Acute  adenitis,  secondary  to  infection  of  the  ulnar  side  of  the  hand  or 
forearm,  develops  in  front  of  the  internal  condyle  or  just  above  it, 
forming  a  tender,  primarily  hard  tumor,  over  which  the  skin  is  freely 
movable.  This  may  subside  or  suppuration  may  occur,  in  which  case 
the  skin  becomes  reddened,  edematous,  and  adherent,  and  softening 
takes  place  in  a  few  days.  There  is  often  associated  axillary  enlarge- 
ment, and  constitutional  symptoms  of  septic  absorption  are  usually 
present. 

Inflammation  of  the  Elbow-joint. — ^The  elbow  follows  the  knee 
in  the  frequency  with  which  it  is  subject  to  inflammation.  When 
distended  by  exudate,  the  elbow-joint  is  fixed  in  a  position  of  slight 
flexion  (130  degrees).  The  swelling  due  to  the  joint  effusion  is  most 
easily  perceived  at  either  side  of  the  olecranon  process  and  triceps 
tendon,  and  between  the  external  condyle  and  the  head  of  the  radius. 

Acute  Arthritis  of  the  Elbow. — ^This  is  usually  traumatic,  rheumatic, 
or  gonorrheal. 

In  its  acute  suppurative  form  it  is  due  to  direct  infection  by  wound 
or  extension  from  surrounding  parts,  as  from  osteomyelitis,  epiphysitis, 
or  periarticular  suppuration;  or  is  a  local  expression  of  a  general 
infection  (pyemia,  typhoid,  pneumonia). 

Acute  traumatic  arthritis,  if  incident  to  contusion  or  sprain,  causing  a 
blood  effusion  into  the  joint,  is  characterized  by  pain,  disability,  dis- 
tention of  the  joint  capsule,  and  moderate  periarticular  swelling,  with 
prompt  (days)  and  complete  subsidence.  Persistent  pain,  tenderness, 
disability,  and  swelling  suggest  a  bone  lesion  or  a  beginning  tuberculosis. 


THE  ELBOW  415 

A  form  of  recurring  traumatic  arthritis  is  that  incident  to  a  loose 
body  in  the  joint,  which  may  be  present  without  symptoms  or  may 
cause  sudden  painful  locking,  limiting  extension,  and  followed  by  effu- 
sion into  the  joint.  The  diagnosis  is  made  by  the  suddenness  of  the 
attacks  of  painful  locking,  their  recurrence,  inexplicable  except  on 
the  basis  of  a  movable  mechanical  obstruction  and,  at  times,  by  the 
detection  of  the  foreign  body  on  palpation. 

Acute  rheumatic  arthritis  of  the  serous  type  is  suggested  by  high  fever, 
acid  sweats,  involvement  of  other  joints,  and  the  absence  of  demon- 
strable systemic  or  local  infectious  cause. 

Acute  gonococcal  arthritis  is  usually  of  the  serofibrinous  and  peri- 
articular form,  is  exceedingly  painful,  obstinately  persistent,  and  results 
in  joint  destruction  and  ankylosis.  The  diagnosis  is  suggested  by  the 
demonstration  of  a  gonococcal  focus  elsewhere,  and  is  made  at  times  by 
bacteriological  examination  of  the  joint  contents. 

Acute  suppurative  arthritis  is  characterized  by  the  rapid  onset  and 
progression  of  local  symptoms  and  the  prompt  development  of  profound 
sepsis.  Early  diagnosis,  when  this  is  not  obvious  from  the  preceding 
history,  should  be  made  by  joint  aspiration. 

Chronic  Arthritis  of  the  Elbow. — This  may  be  post-traumatic,  syphilitic, 
incident  to  other  forms  of  chronic  infection  or  toxemia  or  neuropathic. 
It  is  usually  tuberculous. 

Post-traiunatic  chronic  arthritis  gives  a  history  of  either  severe  or 
frequently  repeated  slight  traumatism.  It  is  characterized  by  bony 
deformity  with  consequent  mechanical  impediment  to  free  mobility, 
together  with  pronounced  periarticular  thickening,  and  pain  on  use. 

Tuberculous  Arthritis. — ^Tuberculous  arthritis  is  characterized,  first, 
by  pain,  limitation  of  motion  and  muscular  atrophy,  which  may 
persist  for  weeks  or  months  preceding  appreciable  swelling.  There 
is  often  at  this  period  a  point  of  greatest  tenderness  to  pressure.  The 
focus  of  infection  is  usually  in  the  ulnar  or  humeral  epiphyses,  excep- 
tionally that  of  the  radius.  In  its  later  development,  the  pallid,  fusi- 
form swelling,  destruction  of  whole  or  part  of  the  joint,  softening,  and 
sinus  formation  are  sufficiently  characteristic. 

The  diagnosis  should  be  suggested  by  a  pain  in  the  elbow  without 
adequate  cause,  persistent  and  growing  worse;  by  limitation  of  motion; 
and  by  muscular  atrophy.  The  seat  of  infection  should  be  determined 
by  the  a;-rays. 

Associated  tuberculous  lesions  elsewhere  or  the  tuberculin  test  may 
aid  in  the  diagnosis. 

SyphiUtic  Arthritis. — Syphilitic  arthritis  of  the  elbow,  aside  from 
that  form  characterized  by  slight  intra-articular  effusion  in  the  early 
secondary  stage,  so  closely  resembles  tuberculous  infection  that  the 
diagnosis  must  be  based  upon  the  history,  associated  symptoms,  the 
therapeutic  test,  and  the  negative  evidence  afforded  by  the  tuber- 
culin test. 

Osteochondritis  of  hereditary  lues  may  cause  epiphyseal  disjunctiou 
and  flail-joint. 


416 


THE   UPPER  EXTREMITY 


Neuropathic  Arthritis. — Neuropathic  arthritis  of  the  elbow  is  symp- 
tomatic of  syringomyeha  or  tabes;  it  is  characterized  early  by  hydrops, 
later  by  gross  bony  deformity  and  rough  crepitation  without  subjective 
symptoms,  the  disability  being  purely  mechanical.  The  diagnosis  is 
based  upon  the  absence  of  pain,  the  surprisingly  slight  disability,  and 
associated  symptoms  of  the  major  malady. 

The  benign  and  malignant  tumors  about  the  elbow  do  not  depart 
from  type.  Those  of  the  bone  are  characterized  early  by  pain  which 
is  persistent  and  localized,  later  by  rapid  growth.  They  should  be 
diagnosticated  by  excision  and  microscopic  examination. 

THE  ARM  AND  SHOULDER. 

The  shoulder  owes  its  rotundity  to  the  deltoid  muscle  supported 
beneath  by  the  acromion  process  and  the  greater  tuberosity  of  the 
humerus.     The   latter,   projecting   beyond   the   anterior   third    of   the 


Trapezius  muscle. 


Outer  end  of  clavicle. 
Most  frequent  site  ot  frac- 
ture of  the  clavicle. 
Acromion  process. 

Infraclavicular  triangle. 
Greater  tuberosity  of  humerus. 
Coracoid  process. 
Lesser  tuberosity. 


Qroove  between  the  del- 
toid and  pectoralis 
major  muscles.  . 


Insertion  of  the  deltoid 
muscle. 


Nipple  in  4th  interspace. 


Prominence  of  triceps. 

Prominence  of  biceps. 

Apex  beat  in  5th  Inter- 
space one  inch  to  Inner 
side  of  nipple. 


Surface  markings  of  arm  and  shoulder.     (G.  G.  Davis  ) 


THE  ARM  AND  SHOULDER  417 

acromial  margin,  underlies  the  most  prominent  (point)  part  of  the 
shoulder,  and,  if  widely  displaced,  as  in  luxation,  allows  the  deltoid  to 
fall  inward,  making  the  acromion  unduly  sharp  and  prominent. 

The  greater  tuberosity  and,  by  outward  rotation,  the  lesser  tuber- 
osity and  the  bicipital  groove  between  them  can  be  felt  in  thin  subjects 
when  there  is  no  local  swelling. 

Since  the  sheath  of  the  long  head  of  the  biceps  communicates  directly 
with  the  joint,  effusions  into  the  latter,  if  abundant,  may  be  detected 
by  swelling  in  the  bicipital  groove. 

The  coracoid  process  can  be  felt  in  the  groove  between  the  great 
pectoral  and  the  deltoid  muscle  by  deep  pressure  a  finger's  breadth 
below  the  junction  of  the  middle  and  outer  third  of  the  clavicle. 

The  clavicle  is  palpable  throughout  its  course;  its  outer  articulation 
is  often  congenitally  placed  on  the  upper  instead  of  the  anterior  sur- 
face of  the  acromial  process,  thus  giving  the  impression  of  displace- 
ment. 

Examination  of  the  shoulder  should  first  be  visual,  the  patient  being 
stripped  to  the  waist  for  comparison  of  the  two  sides.  Then  functional, 
the  patient  attempting  to  move  the  two  arms  together  in  the  directions 
indicated.  Palpation  and  passive  motion  are  next  practised.  Finally, 
in  case  of  doubt,  the  x-rays  should  be  used. 

The  normal  shoulder-joint  should  allow  the  heel  of  the  hand  to  be 
placed  on  the  acromion  process  of  the  opposite  side,  with  the  inner 
surface  of  the  arm  pressed  closely  against  the  chest;  the  palm  to  be 
carried  around  the  opposite  side  until  it  rests  on  the  midposterior  por- 
tion of  the  neck,  with  the  arm  at  a  right  angle  to  the  long  axis  of  the 
body;  both  hands  to  be  carried  backward  until  the  knuckles  of  each 
touch  the  scapular  angle  of  the  other  side;  both  arms  to  be  carried  out- 
ward without  moving  cither  scapula  until  they  form  a  right  angle  with 
the  long  axis  of  the  body;  both  arms  carried  upward  until  the  midbicipital 
region  of  each  touches  the  ear  of  its  corresponding  side.  Normal 
rotation  is  through  about  a  quarter  of  a  circle. 

The  usual  effect  of  trauma  is  bruise  or  sprain,  the  prognosis  of  which 
miist  be  guarded.  Pronounced  periarticular  swelling,  following  trauma, 
is  presumptive  evidence  of  more  serious  injury. 

Obvious  tumors  of  the  deltoid  region  are  usually  not  from  the  joint. 
They  are  generally  fatty,  bursal,  or  sarcomatous.  Joint  inflammations 
limit  motion  in  all  directions,  but  not  equally  so.  Tuberculous  inflam- 
mation involves  the  humerus  and  scapula  more  frequently  than  it  does 
the  joint. 

Sprengel  calls  attention  to  a  congenital  deformity  usually  affecting 
the  scapula  of  the  left  side,  which  is  abnormally  elevated  and  rotated. 
Because  of  the  rotation  the  supraclavicular  space  is  practically  obliter- 
ated. Disability  is  most  marked  when  efforts  are  made  to  elevate 
the  arm.  There  is  often  a  fibrous  or  bony  attachment  of  the  scapula 
to  the  cervical  vertebrae. 
27 


418  THE  UPPER  EXTREMITY 

Deformities  of  congenital  origin,  such  as  absence  of  the  entire  upper 
extremity,  or  shoulder,  insertion  of  the  hand,  the  arm  and  forearm 
being  absent,  are  obvious. 

The  same  may  be  said  of  acquired  deformities,  such  as  the  curved 
and  stunted  humerus  of  rickets,  or  the  atrophied,  flail-hke,  useless 
joint  of  infantile  palsy,  probably  incident  to  birth  traiuna  or  acute 
poliomyelitis. 

Kirmesson  notes  that  in  cases  of  infantile  palsy  the  upper  fibers  of 
the  trapezius  remain  sound  and  hence  are  able  to  raise  the  front  of  the 
shoulder.  An  early  diagnosis  may  enable  much  to  be  done  for  the  pre- 
vention of  ultimate  crippling. 

Limitation  of  motion,  or  ankylosis  of  the  shoulder,  may  follow 
muscular  contracture  or  any  of  the  forms  of  arthritis  or  periarthritis. 
Even  w^hen  the  shoulder-joint  is  completely  ankylosed,  there  may  be 
comparatively  free  movement.  In  conducting  an  examination,  the 
scapula  should  be  grasped  with  one  hand,  while  the  arm  is  moved  in 
various  directions  by  the  other.  In  case  of  complete  joint  fixation, 
the  shoulder  blade  will  be  found  to  participate  in  all  the  movements 
of  the  humerus.  When  the  joint  is  excessively  tender,  a  correct  esti- 
mation of  the  limitation  of  motion  calls  for  the  administration  of  an 
anesthetic. 

Traumatism  of  the  Arm  and  Shoulder. — Wounds  and,  indeed,  all 
severe  traumatisms  call  for  an  examination  of  the  sensory  and  motor 
power  of  the  hand  and  arm,  in  order  to  determine  the  presence  or 
absence  of  nerve  lesion,  and  the  search  for  the  radial  pulse  as  an 
assurance  against  occlusion  of  the  main  artery. 

Rupture  of  the  muscles,  commonly  of  the  biceps,  is  characterized  by 
sharp  pain,  sudden  loss  of  power,  and  the  formation  of  a  soft  tumor, 
pressure  on  which  shows  a  break  in  continuity  aggravated  by  contrac- 
tion. Rupture  of  the  tendon  of  the  biceps  is  characterized  by  the  same 
symptoms.  WTien  the  long  head  of  the  biceps  is  ruptured,  on  account 
of  its  deep  position  the  break  in  continuity  may  not  be  discovered. 
The  disability  and  sharp  pain  incident  to  muscular  action,  often  the 
sensation  of  something  having  given  way,  and  the  partial  luxation 
inward  and  forward  of  the  head  of  the  humerus  are  characteristic. 

Stretching  or  contusion  of  the  nerves  of  the  upper  arm  is  characterized 
by  anesthesia,  loss  of  power,  often  by  persistent  and  harassing  neuritis, 
and  by  muscular  atrophy. 

Contusion  and  Sprain  of  the  Shoulder. — Contusion  is  due  to  direct  force, 
usually  a  fall  on  the  point  of  the  shoulder.  Sprain  is  usually  caused 
by  violent  wrenching  of  the  humerus  upward  or  backward,  or  twisting 
inward.  These  injuries  are  characterized  by  severe  pain,  pronounced 
disability,  tenderness  at  the  point  of  direct  bruise  or  capsular  tear, 
and,  in  the  case  of  sprain,  late  ecchymosis,  often  extensive,  commonly 
appearing  on  the  inner  side  of  the  arm.  The  ruptured  capsule  may 
tear  away  a  fragment  of  bone  with  it. 

The  distinction  from  luxation  is  made  by  finding  the  head  of  the 
humerus  in  its  normal  position;  from  fracture  by  the  absence  of  char- 


THE  ARM  AND  SHOULDER 


419 


acteristic  symptoms  of  this  affection.  The  motions  of  abduction  and 
outward  rotation  are  usually  most  painful  and  are  sharply  limited. 
There  may  be  blood  effusion  into  the  joint,  which,  if  extensive,  may  be 
palpated.  The  reactive  inflammation  often  becomes  chronic  in  the 
middle-aged  and  elderly,  causing  deltoid  atrophy,  weeks  or  months  of 
harassing  pain,  periarthritic  thickening  and  contracture,  and  partial  or 
complete  fixation  of  the  joint. 

Injuries  of  the  shoulder-joint  depart  from  the  rule  that  persistent 
disability  and  tenderness  following  trauma  justify  the  assumption  that 
there  has  been  a  lesion  of  the  bone.  Even  though  clear  x-ray  pictures 
fail  to  show  such  lesion,  the  ultimate  prognosis  of  contusion  or  sprain  of 
the  shoulder  must  be  guarded.  This  disability  is  often  attributable 
to  a  chronic  post-traumatic  inflammation  of  the  subdeltoid  bursa, 
resulting  in  adhesion  of  its  walls  and  obliteration  of  its  cavity. 


Fig.  287 


Paralysis  of  the  serratus  magnus  (long  thoracic  nerve).     Arm  cannot  be  carried  beyond  a  right 
angle  -with  the  long  axis  of  the  body.     Posterior  border  of  the  scapula  prominent. 

Fractures. — Fractures  of  the  shaft  of  the  humerus  (frequent),  trans- 
verse, oblique,  or  spiral,  in  the  latter  case  at  times  comminuted,  are 
usually  due  to  direct  force,  are  simple,  complete,  and  exhibit  all  the 
characteristic  features  of  the  injury.  A  complicating  lesion  to  the 
musculospiral  nerve  at  the  time,  or  later  as  the  result  of  callus  formation. 


420 


THE   UPPER   EXTREMITY 


is  frequently  noted.     Muscular  interposition,  preventing  crepitus  and 
later  causing  non-union,  is  occasionally  observed  in  these  fractures. 

Fractures  of  the  upper  extremity  of  the  humerus  may  involve  the 
head  of  the  bone  or  may  pass  through  the  anatomical  neck.  In  either 
case  the  injury  is  intracapsular.     They  may  pass  through  the  tuber- 


FiG.  2881 


Fig.  289 


Fig.  288. — Oblique  fracture  through  middle  portion  of  shaft,  in  an  adult  male. 

Fig.  289. — Fracture  at  middle  of  shaft,  in  an  adult  fema,le.  Anterolateral  view  shows  line  slightly 
oblique,  marked  displacement,  and  complete  over-riding  with  considerable  shortening,  the  lower 
fragment  being  anterior.  Clinical  diagnosis  of  fracture  easy,  but  a;-rays  important  for  determining 
displacement. 


1  Figs.  288  to  295.  Fractures  of  the  shaft  of  tlie  humerus.  Outline  drawings  from  radiographs 
by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray  Laboratory;  patients  referred 
from  services  of  Drs.  White  and  Siter,  and  private  cases  of  Dr.  Pancoast. 


THE  ARM  AND  SHOULDER 


421 


¥iQ.  290 


Fig.  291 


Fig.  290. — Longitudinal  fracture  involving  middle  third  of  shaft,  in  an  adult  male.  Occurred 
while  throwing  a  baseball.  (Unusual  but  not  uncommon  cause  of  such  fractures.)  An  important 
featiu-e  is  the  fact  that  the  anteroposterior  view  (usually  the  only  one  that  can  be  made  because  of 
the  form  of  dressing),  while  showing  the  fracture,  gave  the  impression  of  perfect  apposition.  The 
lateral  view  here  represented  (taken  with  dressing  removed)  reveals  a  complete  separation.  Under 
such  circumstances  imion  would  either  not  take  place  or  would  be  much  delayed.  Clinical  diagnosis 
of  fracture  not  difficult,  but  a;-rays  very  important  for  determination  of  deformity. 

Fig.  291. — Transverse  fracture  about  junction  of  lower  and  middle  thirds  of  shaft,  in  a  boy,  aged 
nine  years.  Anteroposterior  view  indicates  apparent  good  approximation.  (Compare  with 
Fig.  292.) 


osities  or  beneath  them  (surgical  neck),  may  involve  the  greater  or 
lesser  tuberosity,  or  may  appear  as  comminuted  breaks  representing 
combinations  of  these  forms.  They  are  observed  most  frequently 
in  old  age  or  youth. 

Fracture  of  the  head  of  the  humerus,  usually  fissured  and   without 
displacement,  is  characterized  by  disability,  pain,  and  tenderness,  best 


422 


THE   UPPER  EXTREMITY 


Fig.  292 


Fig.  293 


Fig.  292. — Lateral  view  of  same  case  as  Fig.  291,  shows  almost  complete  forward  displacement 
of  lower  fragment.  Clinical  diagnosis  of  fracture  easy,  but  importance  of  careful  x-ray  examination 
is  apparent. 

Fig.  293. — Comminuted  fracture  in  lower  third  of  shaft,  in  a  girl,  aged  eleven  years,  resulting 
from  a  fall.     Lateral  view  after  reduction  shows  good  approximation. 


elicited  by  deep  axillary  palpation  and  by  jarring  the  head  of  the 
humerus  against  the  articular  surface  of  the  scapula  by  sudden  pressure 
against  the  abducted  and  flexed  elbow.  It  can  be  positively  diagnos- 
ticated only  by  the  x-rays. 

This  is  also  true  of  fracture  of  the  anatomical  neck  (above  the  tuber- 
osities). The  small  intracapsular  fragment  may  be  completely  reversed. 
The  joint  is  unduly  lax,  the  disability  is  absolute,  and  crepitus  may 
be  elicited  by  abduction,  traction,  and  rotation  of  the  humerus,  the 
fingers  of  the  examining  hand  being  pressed  deep  in  the  axilla.  In 
case  of  impaction,  crepitus  will  be  absent  and  all  the  other  symptoms 
will  be  less  marked. 

Fracture  through  the  tuberosities,  epiphyseal  in  young  people  (before 
the  age  of  twenty),  often  impacted  in  older  ones,  results  from  direct 
violence. 

Epiphyseal  fracture  without  deformity  and  impacted  fracture  are 
impossible  to  diagnosticate  without  the  x-rays.  Deformity,  if  it  exists,  is 
usually  due  to  a  forward  and  upward  displacement  of  the  upper  end 
of  the  lower  fragment,  which  may  be  felt  beneath  the  coracoid  process. 
The  presence  of  the  head  in  its  normal  position,  its  failure  to  rotate 
with  the  shoulder,  the  preservation  of  the  shoulder  rotundity,  preter- 
natural mobility,  and  soft  or  grating  crepitus,  exclude  luxation;  more- 


TllK  ARM  AND  SHOULDER 

Fia,  294 


423 


Fio.  295 


Fig.  294. — Multiple  fracture  in  lower  third  of  humerus,  and  compound,  in  a  sailor,  aged  twenty- 
two  years,  resulting  from  a  fall  from  a  great  height.  The  lateral  view  here  represented  was  the 
only  one  possible  at  the  first  examination,  and  indicates  two  separate  fractures  of  the  shaft,  with 
complete  separation  between  upper  and  middle  fragments  (see  Fig.  295). 

Fig.  295.— Same  case  as  Fig.  294,  anterolateral  view  obtained  after  a  change  in  form  of  dressing 
following  a  partial  reduction.  Indicates  an  additional  longitudinal  fracture  of  the  lower  fragment, 
splitting  the  condyles  apart.  This  view  fails,  however,  to  show  the  break  between  the  middle  and 
lower  fragments  which  is  distinctly  evident  in  the  direct  lateral  view. 


over,  the  fracture  occurs  at  a  time  of  life  when  dislocation  is  rare.  From 
fractures  of  the  surgical  neck  the  diagnosis  can  be  made  only  by  the 
a;-rays. 

Fracture  of  the  surgical  neck  (beneath  the  tuberosities)  is  the  one 
most  frequently  found  in  the  upper  extremity  of  the  humerus.  It  is 
especially  common  in  elderly  people  because  of  senile  atrophy.  The 
upper  end  of  the  lower  fragment  projects  upward  and  forward. 
Characteristic  fracture  symptoms  are  usually  present. 

Distinction  from  luxation  is  made  by  the  finding  of  the  head  of  the 


424 


THE   UPPER  EXTREMITY 


bone  in  its  normal  position  and  its  failure  to  rotate  with  the  shaft  of 
the  humerus. 

Impacted  fracture  is  suggested  if,  with  disability  and  pronounced 
pain,  there  is  marked  shortening  as  contrasted  with  the  sound  side, 
the  measurements  being  taken  from  the  acromial  process  to  the  external 
condyle.     When  there  is  doubt,  the  a;-ray  is  needful  for  diagnosis. 

Fractures  of  the  greater  tuberosity  are  usually  complicated  by  other 
injuries,  particularly  by  luxation.  They  may  be  partial  without  dis- 
placement, the  injury  being  suggested  by  persistent  localized  tenderness 
and  pain,  the  latter  markedly  increased  by  voluntary  efforts  at  external 
rotation. 

Isolated  fracture  with  complete  separation  (rare)  is  characterized  by 
free  or  even  exaggerated  rotation,  forward  subluxation  of  the  humeral 
head,  and  possibly  the  detection  of  the  movable  fragment  which  is 
dragged  down  and  out,  broadening  the  shoulder  and  making  the 
acromion  unduly  prominent.  The  long  head  of  the  biceps  may  be 
interposed  between  the  fragments.  When  the  fracture  complicates 
luxation,  it  may  interfere  with  reduction,  and  when  the  latter  is  accom- 
plished, it  permits  easy  recurrence. 

Fracture  of  the  lesser  tuberosity  (rare)  is  suggested  by  inability  to 
actively   rotate    the   arm   inward   and   persistent   localized   pain   and 

Fig.  2961 


Fracture  of  the  anatomical  neck,  caused  by  direct  violence.     Patient  an  adult  male. 


1  Figs.  296  to  308.  Fractures  of  the  upper  portion  of  the  humerus.  Outline  drawings  from 
radiographs  by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  a;-ray  Laboratory;  cases 
referred  by  or  from  services  of  Drs.  White,  Frazier,  Carnett,  Young,  and  Spellissy,  from  dispensaries, 
and  private  cases  of  Dr.  Pancoast. 


THE  ARM  AND  SHOULDER 

Fig.  297 


425 


A  complicated  injury  of  the  shotilder  comprising  the  following  distinct  fractures:  (a)  Fracture 
through  the  surgical  neck;  (b)  a  longitudinal  fracture  extending  downward  through  the  head 
to  the  line  of  the  previous  one,  and  splitting  the  upper  portion  of  the  bone  lengthwise  into  two 
parts;  (c)  a  fracture  of  the  portion  of  the  anatomical  neck  represented  in  one  of  these  fragments; 
and  (d)  a  fracture  of  the  acromion  process  with  wide  separation  of  the  fragment  from  its  clavicular 
attachments.  Such  injuries  are  the  result  of  unusually  severe  violence,  and  in  this  instance  the 
patient,  a  male,  aged  twenty-four  years,  was  struck  by  a  train. 

Fig.  298 


Fracture  of  the  greater  tuberosity  of  the  humerus,  without  separation  of  the  fragment. 
Patient  a  female,  aged  fifty-seven  years. 


426 


THE   UPPER  EXTREMITY 

Fig.  299 


Fracture  of  the  greater  tuberosity,  with  wide  separation  and  displacement  inward  of  the 
fragment.  This  fracture  complicated  a  dislocation  which  was  reduced  before  the  radiograph 
was  made.  The  x-rays  show  it  to  be  not  an  uncommon  complication  of  shoulder  dislocations. 
Patient  a  male,  aged  eighty-six  years. 


Fig.  300 


Fig.  301 


Fig.  300.^Fracture  of  the  greater  tu- 
berosity and  incomplete  fracture  of  the 
anatomical  neck  resulting  from  direct  vio- 
lence by  a  blow  of  a  fist.  Patient  aii  adult 
female. 

Fig.  301. — Fracture  of  the  greater  tu- 
berosity and  incomplete  fracture  of  the 
surgical  neck  resulting  from  direct  violence 
by  striking  the  shoulder  during  a  fall  on 
the  ice.  Patient  a  female,  aged  thirty-six 
years. 


THE  ARM  AND  SHOULDER 


427 


tenderness.  Crepitus  and  mobility  may  be  elicited.  The  x-rays  may 
be  needful  for  diagnosis,  especially  when  it  is  a  complication  of  dis- 
placement. 


Fig.  302 


Old  fracture  of  the  greater  tuberosity  and  the  surgical  neck.  This  injury  was  the  result 
of  an  automobile  accident.  No  diagnosis  of  fracture  was  made  at  the  time,  and  the  patient 
was  treated  for  a  contusion  of  the  shoulder.  The  radiograph  here  represented  was  made  when  she 
consulted  a  surgeon  later  for  an  ankylosis  of  the  joint.  Although  union  was  complete  and  the 
fragments  were  in  fairly  good  apposition,  there  was  firm  fixation  of  the  joint.  Patient  an  adult 
female. 

Fig.  303 


Impacted  fracture  of  the  surgical  neck  with  comminution  of  the  upper  fragment  of  the  head, 
'  which  is  apparently  split  apart  by  the  entering  wedge  of  the  shaft.  Patient  a  male,  aged  forty- 
one  years. 


428 


THE  UPPER  EXTREMITY 


Fig.  304 


Fracture  of  the  surgical  neck,  which,  with  the  accompanying  typical  deformity,  presents  a:i 
appearance  conforming  with  the  usual  graphic  description  of  this  injury.  The  upper  fragment 
is  rotated  outward,  while  the  lower  one  is  displaced  upward  and  inward.  The  nature  of  this 
fracture  and  the  direction  of  the  line  readily  explain  why  the  displacement  shown  had  resisted 
repeated  attempts  at  correction.     Patient  a  female,  aged  fifty-six  years. 


Fig.  305 


Fracture  of  the  surgical  neck  in  a  child,  aged  ten  years.  In  children  the  injury  in  this  part  of 
the  bone  may  be  either  an  epiphyseal  separation  or  a  fracture  of  the  surgical  neck  below  the  line, 
depending  largely  upon  the  nature  and  the  direction  of  the  force. 


THE  ARM  AND  SHOULDER 


429 


Fig.  306 


Fracture  of  the  surgical  neck,  probably  complete,  but  in  some  respects  resembling  an  incom- 
plete fracture.  The  injury  was  due  to  direct  violence.  There  were  no  cardinal  symptoms  of 
fracture  in  this  case,  pain  aggravated  by  rotation  and  local  tenderness  being  the  only  physical 
signs  directly  referable  to  a  break.     Patient  an  adult  male. 

Fig.  307 


Fracture  of  the  shaft  just  below  the  surgical  neck.  Although  complete,  the  only  signs  directly 
referable  to  the  fracture  in  this  case  were  pain  and  local  tenderness,  and  an  exact  diagnosis  was 
dependent  solely  upon  the  x-ray  examination.     Patient  an  adult  male. 


430 


THE  UPPER  EXTREMITY 

Fig.  308 


Subcoracoid  dislocation  of  the  shoulder,  complicated  by  fracture  of  the  tuberosities  of  £he 
humerus,  in  an  adult  female.  ^Clinical  diagnosis  of  dislocation  not  difficult,  but  of  fracture 
uncertain  in  respect  to  exact  seat. 

Fracture  of  the  Scapula. — Fracture  of  the  scapula  is  rare.     These 
fractures  may  be  articular,  a  portion  of  the  joint  surface  being  chipped 

Fig.  3091 


Fracture  of  the  acromion  process.     Patient  an  adult  male. 

1  Figs.  309  to  313.  Fractures  of  the  scapula.  Outline  drawings  from  radiographs  by  Dr.  H.  K. 
Pancoast  in  collection  of  University  Hospital  a;-ray  Laboratory;  patients  referred  by  or  from 
services  of  Drs.  Frazier,  Fussell,  and  White,  from  dispensaries,  and  private  cases  of  Dr.  Pancoast. 


THE  ARM   AND  SHOULDER 

Fig.  310 


431 


Fracture  of  the  coracoid  process.  The  cardinal  symptoms  of  fracture  were  absent  in  this 
case,  the  moderate  degree  of  downward  and  outward  displacement  preventing  crepitus.  The 
condition  was  strongly  suspected  clinically,  but  an  exact  diagnosis  could  not  be  made.  This 
fracture  is  not  only  difficult  to  diagnosticate  clinically,  but  is  very  easily  overlooked  radiographically 
as  well.     Patient  a  male,  aged  fifty-seven  years. 


Fig.  311 


Old  fracture  of  the  lower  portion  of  the  lip  of  the  glenoid  cavity,  with  probably  more  or  less 
union  of  the  somewhat  displaced  fragment,  resulting  in  partial  ankylosis  of  the  shoulder-joint. 
Patient  a  female,  aged  sixty-two  years. 

off  usually  as  a  complication  of  luxation,  or  the  whole  joint  surface 
being  avulsed  (anatomical  neck).  They  may  pass  through  the  surgical 
neck,  the  lesser  fragment  then  including  the  coracoid  process,  through 
the  acromion  process,  the  coracoid  process,  the  spine,  or  any  part  of 
the  body  of  the  bone. 


432 


THE   UPPER  EXTREMITY 
Fig.  312 


Fracture  of  the  surgical  neck  of  the  scapula.  The  line  of  fracture  can  be  seen  only  through 
the  thick  outer  border  of  the  bone,  its  probable  course  upward  toward  the  suprascapular  notch 
being  concealed  by  the  thickened  portions  of  bone  forming  the  root  of  the  coracoid  and  the 
spine,  and  possibly  also  by  some  overlapping  of  the  separated  fragment.  Patient  a  male,  aged 
forty  years. 


Fig.  313 


A  complicated  injury  of  the  shoulder  comprising  four  distinct  fractures:  (o)  The  surgical 
neck  of  the  scapula;  (6)  the  lower  portion  of  the  lip  of  the  glenoid  cavity;  (c)  the  shaft  of  the 
humerus  just  below  the  surgical  neck;  (d)  the  greater  tuberosity  of  the  humerus,  the  fragment  of 
which  is  considerably  displaced  downward  and  inward.     Patient  an  adult  male. 

Fractures  of  the  articular  surface,  usually  limited  to  small  parts, 
or  stellate,  exceptionally  involving  the  entire  articular  surface,  are  diag- 
nosticated by  tenderness,  disability,  crepitus,  and  the  x-rays.     The  last 


THE  ARM  AND  SHOULDER  433 

form  presents  features  much  like  those  of  fracture  of  the  surgical  neck, 
except  that  the  coracoid  process  does  not  move  with  the  humerus  and 
lesser  fragment. 

Fracture  of  the  surgical  neck,  usually  from  direct  violence,  is  char- 
acterized by  dropping  and  abduction  of  the  arm,  flat  shoulder  with 
prominent  acromion,  free  passive  movement,  and  absolute  disability. 
There  is  lengthening  as  measured  from  the  acromion  to  the  external 
condyle.  Deep  axillary  palpation  may  detect  the  fragment,  and  usually 
gives  crepitus  if  the  humerus  is  pushed  up  and  rotated.  The  coracoid 
process  follows  the  motions  of  the  humerus. 

The  easy,  grating  reduction  of  deformity,  by  pushing  up  the  humerus, 
and  its  prompt  recurrence  on  removal  of  pressure,  distinguish  this 
lesion  from  luxation. 

Fractures  of  the  acromion  process  are  in  youth  epiphyseal,  and  are 
complicated  at  times  by  dislocation  of  the  outer  end  of  the  clavicle. 
These  fractures  are  characterized  by  marked  disability  and  tenderness, 
crepitus,  and  slight  mobility,  best  elicited  by  alternately  pulling  and 
pushing  the  abducted  humerus  and  direct  manipulation.  Usually 
there  is  no  deformity. 

The  x-rays  may  be  deceptive  since  the  acromial  epiphysis  may  remain 
permanently  separated  from  the  scapular  spine  by  a  cartilaginous 
plate. 

Fractures  of  the  coracoid  process  (rare)  result  from  direct  trauma 
or  muscular  action.  They  are  characterized  by  disability,  localized 
tenderness,  swelling,  and  crepitus;  if  the  ligamentous  attachments  are 
torn  away,  downward  displacement.  Localized  tenderness,  mobility, 
and  crepitus  may  be  detected  by  deep,  direct  palpation. 

The  diagnosis  of  this  affection  is  theoretical  rather  than  practical, 
except  with  the  aid  of  the  a:-rays. 

Fractures  of  the  spine,  body,  or  angles  of  the  scapula,  due  to  direct  force, 
are  characterized  by  pain,  swelling,  and  usually  but  little  deformity. 
The  detection  of  mobility  and  crepitus  is  diagnostic,  and,  if  the  fracture 
be  complete,  is  easily  accomplished  by  grasping  and  manipulating  the 
bone.  The  traumatic  inflammation  of  the  subscapular  bursa  may 
give  crepitus,  pain,  and  disability,  which  should  not  be  mistaken  for 
fracture. 

Fractures  of  the  Clavicle. — Fractures  of  the  outer  third  of  the  clavicle, 
if  within  the  limits  of  the  coracoclavicular  or  acromioclavicular  liga- 
ments, are  attended  with  localized  pain  and  tenderness,  and  disability, 
but  with  displacement  so  slight  as  to  escape  detection  on  examination, 
though  the  bone  throughout  its  whole  extent  is  subcutaneous.  If  the 
break  be  between  these  ligamentous  attachments,  the  displacement  is 
usually  obvious.  It  is  distinguished  from  luxation  by  the  angularity 
of  the  projecting  fragment  and  crepitus. 

Fractures  of  the  middle  third,  usually  at  the  junction  of  the  middle  and 

outer  third,  may  be  transverse  or  oblique.    They  occur  most  frequently 

in  children   as   the  result  of  a  fall  on  the  hand  or  shoulder,  and  are 

often  incomplete.     The  complete  fracture  is  characterized  by  deformity 

28 


434 


THE   UPPER  EXTREMITY 


which  can  be  seen  and  feh,  mobility  and  crepitus,  detected  by  grasping 
and  manipulating  the  fragments  or  by  raising,  depressing,  and  abducting 
the  shoulder  while  the  seat  of  injury  is  palpated.  There  is  late  (days) 
ecchymosis  over  the  seat  of  injury.  In  the  case  of  children  there  may 
be  surprisingly  little  loss  of  function. 

The  incomplete  fracture,  occurring  usually  in  children,  will  be  char- 
acterized by  sharply  localized  tenderness,  deformity,  late  ecchymosis 
(days),  and  usually  pronounced  disability,  the  arm  hanging  unused  at 


Fig.  3141 


Example  of  the  most  common  type  of  fracture  of  the  clavicle,  at  about  the  junction  of  the 
middle  and  outer  thirds,  showing  also  the  typical  deformity — dropping  of  the  outer  fragment  with 
the  shoulder,  relative  or  actual  upward  displacement  of  the  outer  end  of  the  inner  portion,  and  over- 
riding with  shortening.     Patient,  a  male,  aged  thirteen  years. 

Tig.   .315 


A  typical  example  of  the  so-called  '  'green-stick,"  or  incomplete,  fracture  occurring  at  one  of  its 
most  frequent  seats — the  junction  of  the  outer  and  middle  thirds  of  the  clavicle.  Patient  a  boy, 
aged  eight  years. 


1  Figs.  314  to  316.     Fractures  of  the  clavicle.     Outline  drawings  from  radiographs  by  Dr.  H.  K. 
Pancoast  in  collection  of  University  Hospital  a;-ray  Laboratory;  patients  referred  from  dispensary 


THE  ARM  AND  SHOULDER 

Fig.  316 


435 


Comminuted  fracture   of  the  acromial  end  of  the  clavicle.     The   injury  resulted  from   the 
patieit,  an  adult  male,  "taking  a  header"  from  a  bicycle  and  striking  on  the  shoulder. 

the  side.  At  times  there  is  no  disabihty,  the  fracture  not  being  suspected 
until  ecchvmosis  and,  later  (a  week),  callus  formation  suggest  the  nature 
of  the  lesion. 

Luxations  of  the  Shoulder-joint. — Dislocation  of  the  head  of  the  humerus 
from  the  glenoid  cavity,  the  commonest  of  all  luxations,  is  observed 
chiefly  in  vigorous  adult  males. 

It  is  rare  in  children,  the  traumatic  bone  lesions  in  them  appearing 
as  fractured  clavicle  or  epiphyseal  separation  of  the  humerus.  In  the 
elderly,  fractures  of  the  surgical  neck  of  the  humerus  can  be  expected. 

The  usual  cause  of  luxation  is  direct  or  indirect  violence;  excep- 
tionally it  has  been  due  to  muscular  action,  as  from  throwing  efforts. 

The  forward  dislocations  are  the  subcoracoid  and  subclavicular. 
The  downward  displacement  is  subglenoid;  the  backward,  subacromial 
or  subspinous. 

Common  complications  are  tearing  away  of  muscular  attachments, 
particularly  those  of  the  subscapularis  and  the  supra-  and  infraspinatus, 
and  fracture  of  the  articular  process  of  the  scapula  or  shaft  or  tuberosities 
of  the  humerus.  The  commonest  complicating  fractures  are  those  of 
the  surgical  neck  and  the  great  tuberosity  of  the  humerus. 

The  symptoms  of  luxation  are  pain,  complete  disability,  elastic 
fixation  of  the  arm,  usually  in  slight  abduction,  angularity  due  to  the 
prominence  of  the  acromion  and  the  flattening  of  the  deltoid  bulge 
beneath  it.  There  is  a  depression  felt  beneath  the  anterior  portion  of 
the  acromion  border  where  the  greater  tuberosity  should  normally  form 
a  bulging  projection  (the  point  of  the  shoulder).  The  displaced  head 
of  the  bone  is  felt  in  its  abnormal  position.  The  elbow  stands  out 
from  the  side  and  efforts  to  bring  it  in  contact  with  the  chest  wall  demon- 


436 


THE  UPPER  EXTREMITY 
Fig.  317 


Subcoracoid  luxation  of  right  humerus.  Several  months  old.  Angled  shoulder.  Increased 
width  measured  from  top  of  shoulder  to  lower  border  of  anterior  axillary  fold.  Arm  carried  slightly 
from  side.  A  plane  surface  can  be  made  to  touch  the  external  condyle  and  the  outer  acromial 
border.     Forearm  flexed. 

Fig.  318 


■  Recent  subcoracoid  luxation  of  humerus.    The  characteristic  features  shown  at  Fig.  317  somewhat 

obscured  by  swelling. 


THE  ARM  AND  SHOULDER  437 

strate  an  elastic  resistance,  nor,  even  in  the  subclavicular  displacement, 
can  the  hand  of  the  injured  side  be  carried  to  the  sound  shoulder  and 
the  elbow  be  brought  in  contact  with  the  chest  wall.  This  last  test 
fails  when  the  capsule  and  muscular  attachments  of  the  humerus  have 
been  extensively  torn,  and  in  enormously  fat  people. 

In  all  cases  there  is  an  increase  in  the  circumference  of  the  shoulder 
and  a  departure  from  normal  in  the  direction  of  the  long  axis  of  the 
humerus  as  contrasted  with  that  of  the  sound  side.  With  the  arm 
rotated  inward  and  pressed  as  close  to  the  side  as  is  possible,  a  plane 
surface  can  be  made  to  touch  the  external  epicondyle  and  the  anterior 
portion  of  the  outer  margin  of  the  acromion.  This  is  impossible  unless 
the  greater  tuberosity  is  displaced. 

The  subglenoid  luxation  is  characterized  by  the  ease  with  which  the 
head  of  the  bone  can  be  felt  by  axillary  palpation  and  by  pronounced 
abduction  which  exceptionally  may  carry  and  hold  the  elbow  out  so 
far  that  the  arm  makes  almost  a  right  angle  with  the  long  axis  of 
the  body.  In  this  form  of  luxation  there  is  sometimes  lengthening  as 
measured  from  the  acromion  process  to  the  external  condyle.  The  sub- 
coracoid  and  subclavicular  displacements  are  characterized  by  finding 
the  head  of  the  bone  in  the  position  indicated  by  the  name.  In  both 
the  elbow  is  carried  outward  and  backward. 

The  backward  luxations,  subacromial  or  subspinous,  are  rare  and  char- 
acterized by  prominence  of  the  acromial  process,  often  of  the  coracoid, 
and  the  presence  of  the  rounded  tumor  made  by  the  head  of  the  humerus, 
either  beneath  the  posterior  border  of  the  acromion,  where  there  is 
normally  a  depression,  or  the  spine  of  the  scapula.  Unless  there  be 
extensive  muscular  rupture,  the  arm  is  fixed  in  a  position  of  adduction 
and  internal  rotation. 

The  diagnosis  of  complicating  fractures,  if  these  involve  the  shaft 
of  the  bone,  is  dependent  upon  finding  the  glenoid  cavity  empty,  the 
head  of  the  bone  in  its  abnormal  position,  and  preternatural  mobility 
and  crepitus  elicited  by  direct  palpation  and  adduction,  abduction,  and 
rotation  of  the  humerus.  If  the  surgical  neck  be  broken,  the  head 
and  tuberosities  will  not  participate  in  passive  movements  of  the  shaft. 

Fracture  of  the  glenoid  cavity  is  suggested  by  crepitus  on  deep  pal- 
pation and  by  difiiculty  of  retention  after  reduction  is  accomplished. 

Fracture  of  the  tuberosity  and  of  the  surgical  neck  of  the  scapula 
are  likely  to  escape  detection  in  the  presence  of  the  rapid  and  extensive 
swelling  which  follows  dislocation,  without  the  help  of  the  x-tsljs. 

Although  the  symptoms  of  dislocation  of  the  shoulder-joint  are 
fairly  marked,  determination  of  the  presence  or  absence  of  this  lesion 
may  be  difficult  in  fat,  muscular  subjects,  since  the  examination  is  always 
painful.  In  case  of  doubt,  examination  should  be  conducted  under 
full  anesthesia,  and,  as  is  the  case  with  all  injuries  about  joints,  the 
rr-rays  should  be  used. 

The  examination  of  a  case  of  shoulder  luxation  should  not  be  con- 
cluded until  the  surgeon  has  assured  himself  of  the  integrity  of  the 
neighboring  vessels  and  nerves. 


438 


THE   UPPER  EXTREMITY 


If  the  circumflex  nerve,  winding  around  the  surgical  neck  of  the 
humerus  and  supplying  the  joint,  the  deltoid,  and,  by  a  cutaneous 
branch,  the  skin  over  the  lower  third  of  this  muscle,  be  permanently 
injured,  deltoid  atrophy  will  follow.  Anger  states  that  such  injury  may 
be  suspected  if  immediately  following  trauma  there  is  anesthesia  in  the 
skin  area  supplied  by  this  nerve. 

The  axillary  artery  may  be  torn  without  immediate  colossal  hemor- 
rhage. Such  complication  should  be  at  least  considered  if  on  first 
examination  the  radial  or  brachial  pulse  cannot  be  felt. 

Luxation  of  the  Clavicle. — Either  the  outer  or  the  inner  extremity  of 
the  clavicle  may  be  displaced,  either  by  direct  or  indirect  force.  Dis- 
placement of  the  outer  end  is  characterized  by  extreme  pain  and 
pronounced  disabihty.  Undue  mobihty  and  displacement  are  readily 
detected.  Congenital  eccentricity  of  conformation  may  lead  to  error 
in  the  case  of  the  acromioclavicular  joint. 


Fig.  319 


Seborrheic  eczema  of  the  axilla.     (Hartzell.) 

Inflammatory  Affections  of  the  Arm  and  Shoulder. — Acute  inflam- 
mation of  the  soft  parts  of  the  arm  and  shoulder  conform  to  type  in 
etiology  and  symptoms. 

Seborrheic  eczema  and  tinea  are  fairly  common  in  the  axilla. 

This  region  is  a  common  seat  of  follicular  abscesses  which  develop 
successively  in  fresh  crops,  usually  beginning  as  red,  tender,  shot-like 
skin  nodules  which  shortly  suppurate.  They  are  extremely  painful  and, 
because  of  their  position,  cause  disability.  These  abscesses  may  originate 
either  in  the  sebaceous  or  the  sudoriferous  glands.  In  the  latter  case 
they  are  placed  more  deeply  and  are  of  larger  size. 


THE  ARM  AND  SHOULDER 


439 


At  times  these  subcutaneous  abscesses  are  the  starting  points  of  diffuse 
cellulitis  and  are  accompanied  by  symptoms  of  profound  septic  absorp- 
tion. They  are  occasionally  complicated  by  suppurating  axillary 
glands. 

Abscesses  beneath  the  deep  fascia  are  usually  of  lymphatic  origin, 
incident  to  infection  of  any  of  the  areas  draining  into  these  glands; 
they  may  be  secondary  to  osteomyelitis  of  any  of  the  bones  adjoining 
the  axillary  space  or  may  be  caused  by  a  perforating  pleurisy.  They 
may  reach  huge  proportions,  burrowing  widely  beneath  the  pectorals 


Fig.  320 


Tinea  of  the  axilla.     (Hartzell.) 

and  the  clavicle.  These  burrowing  abscesses  cause  profound  systemic 
poisoning.  The  diagnosis  is  based  on  the  diffuse  swelling,  fluctuation, 
surface  edema,  and  constitutional  symptoms  of  sepsis. 

Acute  axillary  adenitis,  characterized  by  tender  swollen  axillary 
nodules,  secondary  to  wounds  of  the  hand,  arm,  shoulder,  or  side  of 
the  chest,  usually  undergoes  resolution  on  proper  drainage  of  the 
original  focus  of  infection. 

Acute  Suppurative  Inflammation  of  the  Subdeltoidean  Bursa. — This  is 
evidenced  by  obvious  swelling,  most  pronounced  in  its  beginning  just 
below  the  margin  of  the  anterior  third  of  the  acromion,   associated 


440  THE   UPPER  EXTREMITY 

with  extreme  tenderness  at  this  point,  followed  shortly  by  a  swelling 
which  completely  obscures  the  point  of  the  shoulder,  edema  of  the  skin, 
and  marked  limitation  of  the  motions  of  the  humerus  in  the  outward 
and  forward  direction.  It  is  usually  a  manifestation  of  systemic  infec- 
tion; very  exceptionally  it  follows  traumatism. 

The  diagnosis  is  based  upon  the  position  of  swelling.  Intra-articular 
effusions  never  form  a  projecting  tumor  at  the  point  of  the  shoulder.  On 
deep  axillary  palpation  the  joint  is  not  tender,  and  only  those  motions 
are  painful  which  directly  affect  the  inflamed  bursa.  The  constitutional 
symptoms  are  those  of  septic  absorption.  The  ic-rays  indicate  the 
position  of  the  inflammation. 

Acute  Osteomyelitis  of  the  Humerus. — This  is  less  common  than  is  the 
case  with  the  tibia  or  femur  and  usually  attacks  the  upper  extremity  of 
the  bone.  Although  the  focus  is  situated  at  or  near  the  epiphysis,  the 
line  of  diaphyseal  junction  being  extra-articular,  the  joint  is  usually 
spared,  the  abscess  appearing  externally. 

Diagnosis  is  based  upon  severe  pain,  localized  tenderness  on  deep 
pressure,  rapid  edematous  swelling  of  the  soft  parts,  disability  and 
constitutional  signs  of  acute  sepsis.  Freedom  of  passive  motion  and 
absence  of  tenderness  on  direct  palpation  exclude  arthritis  of  the  shoulder. 
In  young  people,  epiphyseal  separation  and  subsequently  marked  im- 
pairment of  bone  growth  are  common  sequelae. 

Multiple  foci  of  infection  throughout  the  shaft  of  the  bone  cause 
tenderness  to  deep  pressure  and  marked  edematous  swelling  of  the 
entire  arm,  together  with  the  symptoms  of  profound  sepsis.  They  are 
followed  by  necrosis  and  the  formation  of  sequestra. 

As  in  the  other  bones,  the  inflammation  may  subside  without  pro- 
ducing gross  necrosis,  or  may  continue  indefinitely,  in  the  chronic  form 
producing  great  thickening  of  the  bone  accompanied  by  harassing  pain 
and  localized  tenderness. 

Acute  serous  and  serofibrinous  arthritis  may  be  secondary  to  trauma 
or  periarticular  inflammation  (osteomyelitis,  the  infection  not  reach- 
ing the  joint),  but  is  usually  a  local  expression  of  constitutional  infec- 
tion (gonorrheal,  rheumatic,  typhoidal,  pneumonic,  influenzal,  exan- 
thematous).  It  is  characterized  by  severe  pain,  rapid  in  onset,  and 
crippling  in  intensity,  greatly  aggravated  by  passive  movement  in  any 
direction  but  particularly  by  that  of  abduction,  limitation  of  the  motions 
of  the  shoulder  in  all  directions  and  tenderness  on  pressure  best  marked 
at  first  where  the  joint  can  be  most  nearly  approached  by  the  examining 
finger  (axilla,  bicipital  groove).  There  is  little  appreciable  swelling 
even  on  careful  palpation.  Indeed,  an  obvious  swelling  of  the  shoulder, 
except  as  the  result  of  acute  suppuration  or  of  a  long-standing  disease, 
practically  excludes  the  shoulder-joint  as  the  seat  of  disease. 

Acute  Suppurative  Arthritis  of  the  Shoulder. — This  is  secondary  to  an 
infected  wound,  osteomyelitis,  or,  rarely,  general  infection  (pyemia, 
pneumonia,  smallpox).  It  is  characterized  by  intense  pain,  rapid  and 
diffuse  edematous  swelling,  total  disability  with  joint  fixation,  and  con- 
stitutional symptoms  of  profound  sepsis. 


THE  ARM  AND  SHOULDER 


441 


The  early  diagnosis  should  be  made  by  aspiration  and  examination 
of  the  fluid. 

Chronic  Inflammation  of  the  Arm  and  Shoulder. — Syphilitic  Myositis. 
— Syphilitic  myositis  of  the  biceps  may  develop  in  the  secondary  or  the 
tertiary  period  of  the  disease.  In  the  former  case  it  is  rapid  in  onset 
(days),  is  characterized  by  pain  and  stiffness  on  motion,  by  slight  tender- 
ness and,  possibly,  diffuse  swelling.     It  is  usually  considered  rheumatic. 

Fig.  321 


Epithelioma  in  cicatrix.  Extensive  burn  of  arm  and  chest.  Complete  healing  with  adhesion 
between  arm  and  chest.  Epitheliomatous  ulceration  of  cicatrix  twelve  months'  duration.  Slough- 
ing, bleeding  ulcer  with  everted  indurated  edges.  Edema  of  hand  from  venous  and  lymphatic 
obstruction.     (Carnett.) 


In  the  tertiary  form  contracture  of  the  muscle  is  the  dominant 
symptom;  the  forearm  becomes  gradually  flexed  on  the  arm,  nor  can 
it  be  extended.  The  biceps,  painful  and  tender  at  first,  later,  swollen, 
undergoes  gradual  atrophy.  The  triceps  muscle  is  sometimes  affected 
in  the  same  way,  the  contracture  then  limiting  flexion. 

This  muscular  contracture  is  in  itself  almost  diagnostic  of  syphilis. 
It  yields  rapidly  to  constitutional  treatment  unless  this  has  been  post- 


442  THE   UPPER  EXTREMITY 

poned    until   muscular   degeneration   and   permanent   cicatricial    con- 
tracture have  taken  place. 

Gumma  and  tuberculous  abscess,  noted  in  both  the  biceps  and  triceps 
muscle,  can  be  distinguished  from  neoplasm  in  their  early  course  only 
by  operation. 

Inflammatory  hyperplasia  of  the  axillary  glands,  characterized  by 
nodular,  usually  non-sensitive  swellings,  may  follow  infection  or  trau- 
matism of  any  of  the  areas  drained  into  these  glands.  From  the  arm 
and  hand,  the  lymph  is  received  by  that  group  which  lies  along  the 
vessels;  from  the  breast,  thorax,  and  upper  abdomen,  by  the  group 
lying  along  the  lower  axillary  border  of  the  great  pectoral  muscle. 
The  subscapular  and  subclavicular  group  drain  the  shoulder  and  back. 
These  groups,  however,  freely  intercommunicate.  The  pectoral  and 
vascular  groups  are  the  ones  chiefly  involved  in  chronic  inflammation 
of  the  breast  or  hand. 

Tuberculous  adenitis,  usually  secondary  to  tuberculosis  elsewhere, 
or  associated  with  it,  particularly  with  involvement  of  the  glands  of  the 
neck,  pursues  the  same  course  as  that  characteristic  of  tuberculous 
glands  in  general. 

Neuritis. — Neuritis,  usually  post-traumatic,  at  times  ascending  from 
a  peripheral  lesion,  is  characterized  by  extreme  tenderness  along  the 
course  of  the  nerve,  loss  of  function,  and  muscular  degeneration. 
Harassing  pain  referred  along  the  course  of  the  brachial  plexus,  partic- 
ularly in  its  ulnar  distribution,  relieved  by  posture  and  unattended  by 
the  characteristic  features  of  neuritis  is  sometimes  attributable  to  droop- 
ing shoulder  and  relaxed  ligaments  (Goldthwait). 

Bursitis. — There  is  at  times  developed  an  adventitious  bursa  on  the 
inner  surface  of  the  serratus  magnus  muscle  placed  at  either  the  upper 
or  lower  angle  of  the  scapula.  This,  when  chronically  inflamed,  may 
give  rise,  on  motion,  to  an  annoying  grating  without  any  other  symp- 
toms.    Or  it  may  be  associated  with  considerable  pain. 

The  diagnosis  is  based  upon  the  seat  of  pain  and  grating  and  the 
dependence  of  these  symptoms  upon  scapular  movements. 

Acromial  Bursitis. — Acromial  bursitis  due  to  repeated  slight  trauma, 
as  from  carrying  weights  on  the  shoulder,  is  characterized  by  a  soft, 
smooth,  fluctuating,  dome-shaped  tumor  placed  between  the  skin  and 
the  summit  of  the  acromion  process.  The  free  mobility  of  the  over- 
lying skin  and  absence  of  lobulation,  distinguish  this  bursitis  from 
lipoma.  As  the  result  of  trauma,  this  chronic  bursitis  may  become 
acutely  suppurative. 

Subdeltoidean  Bursitis — The  subdeltoid  bursa  lies  between  the  under 
surface  of  the  deltoid  muscle  and  the  acromial  process  (subacromial 
portion)  and  the  upper  surface  of  the  supraspinatus  tendon  and  the 
greater  tuberosity  of  the  humerus. 

The  inflammation  is  usually  fibrinous  and  adhesive  in  type,  is  post- 
traumatic, and  is  characterized  by  tenderness  elicited  by  deep  pressure 
against  the  greater  tuberosity,  just  below  the  anterior  third  of  the  outer 
acromial  border.     There  is  pain,  constant  or  recurrent  and  harassing. 


THE  ARM  AND  SHOULDER 


443 


radiating  along  the  outer  surface  of  the  arm,  greatly  aggravated  by 
voluntary  or  passive  movements  of  the  humerus,  either  outward  or 
forward,  ultimately  muscular  atrophy  and  a  subluxated,  stiff  joint. 

Exceptionally  this  chronic  bursitis,  when  subject  to  repeated  slight 
trauma,  forms  either  a  large  hygroma  or  a  hard,  palpable  tumor  with 
cheese-like  contents. 

Fig.  322 


Dissection  of  an  injected  subdeltoidean  bursa.      (Baer.) 


The  diagnosis  can  be  suspected  from  the  position  of  the  tumor,  its 
sensitiveness,  the  distribution  of  the  pain  area,  the  character  of  the 
disability,  and  the  x-raj  picture.  It  can  be  made  surely  only  by 
incision  and  microscopic  examination  of  the  removed  bursa. 

Tuberculous  subdeltoidean  bursitis  is  characterized  by  the  almost 
painless  formation  of  a  soft  tumor  in  the  position  of  the  bursa,  which 


444 


THE  UPPER  EXTREMITY 

Fig.  323 


Chronic  subdeltoidean  bursitis.      Both  arms  are  abducted  to  their  full  extent.      (Baer.) 

Fig.  324 


Chronic  traumatic  subacromial  bursitis.  Duration,  months.  Pain  and  disability  marked. 
Complete  abduction  still  possible,  but  accomplished  with  much  difficulty.  When  the  arm  is  carried 
from  the  side  as  far  as  shown  in  the  illustration,  it  is  by  a  swinging  motion  of  the  shoulder  rotated 
outward,  after  which  it  can  be  carried  above  the  head.  On  bringing  the  arm  down  to  the  side, 
the  motion  is  reversed.     In  many  cases  the  complete  abduction  is  impossible. 


THE  ARM  AND  SHOULDER  445 

on  manipulation  gives  the  crepitation  or  chain-like  grating  incident  to 
the  villous  growth  from  its  inner  surface  or  the  rice-like  bodies  it  usually 
contains.  In  the  absence  of  crepitation  the  affection  simulates  fatty 
tumor,  but  is  much  more  rapid  in  growth. 

From  sarcoma,  it  should  be  distinguished  by  operation,  since  a  malig- 
nant tumor  so  placed  as  to  suggest  chronic  bursitis  cannot  be  distin- 
guished from  this  affection. 

Subcoracoid  Bursitis. — The  coracobrachial  bursa  lies  between  the  tip 
of  the  coracoid  process  and  the  joint  capsule  overlying  the  lesser 
humeral  tuberosity.  Inflammation  of  the  bursa  is  characterized  by 
pain  particularly  marked  in  rotation  and  by  limitation  of  the  same 
motion.  There  may  be  a  constant  or  recurring  pain  often  referred 
down  the  arm,  and  pronounced  disability 

Fig.  325 


Chronic  traumatic  subacromial  bursitis.    The  arm.  has  been  rotated  outward  and  is  being  carried  up 

Chronic  Inflammation  of  the  Bones  and  Joints  of  the  Arm  and 
Shoulder. — Chronic  Osteomyelitis  of  the  Humerus. — This  may  be  sequent 
to  an  acute  attack  which  subsides  without  producing  gross  necrosis.  The 
inflammation  continues  indefinitely,  producing  great  thickening  of  the 
bone,  accompanied  by  harassing  pain  and  localized  tenderness.  There 
may  be  a  central  sequestrum  without  pus. 

Tuberculosis  of  the  Humerus. — ^Tuberculosis  of  the  humerus  rarely 
affects  the  shaft  of  the  bone.  Its  presence  is  suggested  by  pain  and 
localized  tenderness. 

Tuberculosis  of  the  upper  epiphysis  is  less  prone  to  involve  the  joint 
than  is  the  affection  when  it  attacks  the  lower  epiphysis.  Deep-seated 
pain,  persistent  tenderness,  and  disinclination  to  use  the  part,  these 
symptoms  gradually  (weeks  or  months)  growing  worse  and  finally 
supplemented  by  tumor,  softening,  and  the  formation  of  sinuses  leading 
to  dead  bone,  are  characteristic  features. 


446 


THE  UPPER  EXTREMITY 


The  diagnosis  in  the  early  stages  of  the  affection  will  be  suggested 
by  a  tuberculous  family  history  and  the  presence  elsewhere  of  lesions 
of  the  disease.  It  should  be  made  by  the  a:-rays  before  visible  or  pal- 
pable tumor  formation;  by  incision  as  soon  as  a  bone  swelling  can  be 
detected. 

Gummatous  Osteitis. — Gummatous  osteitis  of  the  humerus,  charac- 
terized by  local  tenderness,  often  extreme  pain  and  tumor  formation, 
can  be  distinguished  in  its  early  stage  from  tuberculosis  or  malignant 
growth  only  by  a  suggestive  history,  associated  with  other  more  char- 
acteristic lesions  and  the  prompt  effect  of  specific  treatment. 

Both  syphilitic  and  tuberculous  osteitis  attack  the  scapula.  Each 
affection  develops  according  to  type. 

The  inner  extremity  of  the  clavicle  is  a  favorite  seat  for  gumma. 

Fig.  326 


Gumma  of  the  sternal  end  of  the  clavicle.    Tertiary  period  (years).    Painless  indurated  growth 
from  bone  with  central  softening.     Duration,  one  week. 


Chronic  Arthritis  of  the  Shoulder. — Chronic  arthritis  of  the  shoulder 
is  usually  traumatic,  often  toxic  or  infectious  (rheumatoid  arthritis, 
arthritis  deformans),  exceptionally  neuropathic  (syringomyelia  and 
tabes). 

Traumatic  chronic  arthritis  may  follow  severe  injury,  being  then 
incident  to  bone  and  capsular  lesions  which  even  after  recovery  leave 
the  joint  so  mechanically  altered  that  ordinary  use  represents  a  con- 
stantly recurring  trauma;  or  it  may  be  the  result  of  long-continued 
overuse,  as  in  the  case  of  laborers.  It  is  an  affection  of  old  age,  char- 
acterized by  deformities  typical  of  rheumatoid  arthritis  or  osteoarthritis. 
Pain,    weakness,    muscular    atrophy,    subluxation,    and    limitation    of 


THE  ARM  AND  SHOULDER  447 

motion,  together  with  grating  crepitus,  are  present.  Complete  ankylosis 
is  rare. 

Tuberculous  Arthritis  of  the  Shoulder. — This  is  rare  as  compared  to 
the  frequency  of  the  inflammation  in  other  large  joints.  It  exhibits 
a  predilection  for  that  form  of  the  affection  characterized  as  dry  caries, 
the  bone  being  softened  and  abraded,  often  without  the  formation  of 
a  sinus  discharging  externally. 

The  affection  is  characterized  by  pain,  intermittent  at  first,  limita- 
tion of  joint  movement  with  muscular  atrophy,  and  tenderness  on 
palpation  of  the  head  of  the  bone  in  the  axilla  or  in  the  bicipital  groove 
to  the  inner  side  of  the  greater  tuberosity.  As  the  head  of  the  humerus 
disappears  by  absorption,  the  acromion  projects  sharply.  Periarticular 
swelling  may  be  slight  or  may  be  pronounced. 

The  early  diagnosis  of  joint  involvement  is  suggested  by  limitation 
of  motion  in  all  directions,  tenderness  elicited  by  direct  palpation  and 
by  upward  jars  of  the  elbow,  muscular  atrophy,  and  the  skiagram. 
These  symptoms  will  distinguish  a  caries  sicca  from  malignant  growth, 
which  is  always  in  the  beginning  extra-articular. 

The  fungous  form  of  arthritis  of  the  shoulder  corresponds  to  type 
as  seen  in  other  joints.     The  bursse  are  very  commonly  involved. 

Neuropathic  Arthritis  of  the  Shoulder. — Neuropathic  arthritis  of  the 
shoulder,  secondary  to  syringomyelia  or  tabes,  is  characterized  often  by 
extraordinary  bone  deformity,  absence  of  pain,  and  function  limited 
only  by  the  obstruction  to  movement  offered  by  the  bony  outgrowths. 

Neurosis  of  the  Shoulder-joint. — Neurosis  of  the  shoulder-joint,  when 
it  occurs  in  an  hysterical  female  skilled  in  the  ways  of  doctors,  is  the 
most  difficult  of  all  the  affections  of  this  region  to  diagnosticate. 

Tumors  of  the  Arm  and  Shoulder. — The  tumors  of  the  skin  and 
subcutaneous  fascia  of  the  arm  are  those  common  to  these  tissues. 
Lipoma  is,  perhaps,  the  commonest  tumor.  In  fat  people,  painful 
fibrolipomata  are  at  times  observed. 

Indurations  of  bony  hardness  are  observed  both  in  the  brachialis 
anticus  and  the  deltoid,  incident  to  repeated  trauma.  They  are  tender 
on  pressure,  but  occasion  little  pain  or  disability  aside  from  the  mechani- 
cal one,  nor  do  they  exhibit  any  tendency  toward  growth. 

Sarcoma  of  the  muscles  cannot  be  distinguished  as  such  from  tuber- 
culous abscess  or  gumma  at  a  time  when  this  is  profitable,  except  by 
excision. 

Fibroma. — Fibroma  has  a  peculiar  predilection  for  the  nerve  trunks 
of  the  arm.  It  is  characterized  by  a  hard,  fusiform,  painful,  and  tender 
tumor  in  the  course  of  the  nerve,  laterally  mobile,  but  not  in  the  long 
axis  of  the  nerve,  and  causing  sensory,  sometimes  motor,  disturb- 
ance in  regions  supplied  by  the  involved  nerve.  It  is  distinguished 
from  myxoma  or  sarcoma  of  the  nerve  trunks  (malignant  neuroma) 
by  its  slow  growth.  Its  position  on  the  nerve  is  characteristic.  It 
should  be  diagnosticated  by  the  microscope  before  it  is  unmistak- 
ably malignant. 


448  THE   UPPER  EXTREMITY 

Lipoma. — Lipoma  is  the  commonest  tumor  about  the  shoulder.  It 
is  slow  in  growth,  subdermal,  soft  distinctly  lobulated,  and  adherent 
to  the  skin.  Its  lobulation  and  skni  attachments  distinguish  it  from 
a  supra-acromial  chronic  bursitis.  Even  when  placed  beneath  the 
fascia,  diagnosis  is  difficult  only  in  its  early  course  when,  by  pressure 
on  nerves,  the  lipoma  may  produce  pains  radiating  down  the  arms 
and  distinct  muscular  weakness.  Diagnosis  then  can  be  made  only 
by  incision. 

Lipoma  is  common  in  the  axilla,  at  times  associated  with  angioma. 

An  aberrant  mammary  gland  may  occur  in  the  axilla,  closely  simu- 
lating fatty  tumdr. 

Osteoma. — Exostoses  as  the  after  result  of  traumatism,  or  as  a  local 
manifestation  of  a  general  process,  are  observed  on  the  humerus;  they 
are  characterized  by  indolence,  painlessness,  bony  hardness,  and  slow 
growth  (years).  The  same  may  be  said  of  chondromata  and  cysts. 
The  latter,  when  they  reach  moderate  size,  are  attended  by  the 
crackling  sensation  characteristic  of  the  well-developed  myeloid  sar- 
coma. Nor  can  the  differential  diagnosis  be  made  except  by  microscopic 
examination. 

Sarcoma. — Sarcoma  is  the  usual  tumor  of  the  deltoid  and  of  the  muscles 
surrounding  the  shoulder-joint.  In  its  full  development  the  diagnosis 
is  unmistakable;  in  its  early  stage,  its  nature  is  suspected  on  the  basis 
of  probability  and  because  of  rapid  growth.  Diagnosis  is  made  by 
excision  and  microscopic  examination. 

Sarcoma  originating  from  any  of  the  structures  of  the  axilla,  par- 
ticularly the  lymph  glands  and  the  nerve  sheaths,  exhibits  its  ordinary 
characteristics,  i.  e.,  the  rapid  growth  of  a  round,  sharply  outlined, 
solid  tumor.  The  early  diagnosis  from  inflammatory  hyperplasia  of 
a  lymphatic  gland  or  tuberculous  adenitis  is  based  on  the  causeless- 
ness  of  the  sarcoma,  rapidity  of  growth  and,  later,  on  the  size  of  the 
tumor.     It  should  be  made  by  early  excision. 

Cavernous  Angioma. —  Cavernous  angioma  may  sometimes  suggest 
aneurysm,  but  is  differentiated  from  this  affection  by  the  obvious  skin 
involvement,  by  the  absence  of  typical  expansile  pulsation  and  bruit, 
and  by  the  slight  effect  produced  upon  it  by  pressure  upon  the  sub- 
clavian artery. 

Lymphangioma. — Lymphangioma  forms  a  cystic  tumor  in  the  axilla 
of  infants  which  in  its  development  passes  up  beneath  the  pectoralis 
minor  and  clavicle,  and  presents  in  the  neck,  forming  a  bilocular  growth. 
Its  characteristics  are  those  of  the  same  tumor  as  observed  in  the 
neck.  Bleeding  into  such  a  cyst  is  the  usual  cause  of  non-traumatic 
hematoma. 

Carcinoma. — Carcinomatous  glands  of  the  axilla  are  secondary  to 
cancer  of  the  area  from  which  the  lymph  is  drained,  usually  the  breast. 
In  their  early  stage  they  cannot  be  distinguished  from  glands  enlarged 
by  inflammatory  h}^erplasia. 

Tumors  of  the  humerus  are  commonest  about  the  upper  epiphysis. 
They  are  usually  sarcomatous.     In  the  early  stage  they  are  character- 


THE  ARM  AND  SHOULDER 


449 


ized  by  persistent  bone  pain  and  localized  tenderness;  later  by  swelling, 
which,  if  allowed  to  develop,  becomes  entirely  characteristic.  If  the 
growth  is  rapid,  there  is  fever  and  toxic  anemia. 


Fig.  327 


Metastatic  carcinoma  of  humerus.     Pathological  fracture.     Operation  for  cancer  of  breast  two 
years  previously.     Metastasis   present  in  liver.     (Carnett.J 

There  are  no  characteristic  features  which  early  distinguish  these 
tumors  from   tuberculous  or  syphilitic    osteitis  or  osteomyelitis.     The 
29 


450 


THE   UPPER  EXTREMITY 


diagnosis  must   be  made   by  incision  guided  by  ic-ray  pictures  and 
microscopic  examination.     In  the  later  stage  of  these  growths,  rapid 


Fig.  328 


Metastatic  carcinoma  of  humerus.     Primary  in  breast.    Multiple  foci  in  humerus.     First  symptom 
observed  was  fracture  on  turning  patient  in  bed.     (Carnett.) 


increase  of  size,  the  destruction  of  bone  substance,  surface  vascularity 
and  discoloration,  metastases,  and  cachexia  enable  the  diagnosis  to 
be  formulated. 


CHAPTEK    XV. 


THE  THORAX. 


Congenital  malformations,  such  as  those  due  to  absence  or  deficient 
development  of  the  pectoral  muscles,  of  the  sternum,  or  the  ribs,  are 
obvious  to  inspection  and  palpation.  A  funnel-like  depression  of  the 
lower  part  of  the  sternum  is  frequently  seen  and  occasions  no  symptoms. 
The  asymmetry  due  to  rickets  is  expressed  in  the  form  of  pigeon-breast, 
the  beading  of  the  ribs,  so  characteristic  in  infancy,  later  disappearing. 


Fig.  329 


Pylorus  opposite 
the  Rth  cartilage 
one  inch  to  right 
of  median  line. 

Gall  bladder  op- 
posite tip  of  the 
9th  costal  cartilage. 


Surface  markings  of  the  thorax  and  abdomen 


Tip  of  xiphoid  cartilage. 

Median  line  (linea  alba). 

Rectus  muscle. 

Linea  semilunaris. 

Lower  edge  of  stomach. 

Lower  edge  of  trans,  col. 
Unabilicus  bet.3d  and  4th 

lumbar  verlebrse 
Top  ol  crest  of  ilium 

Anterior  superior  spine. 

Poupart's  ligament. 
Inter,  abdominal  ring. 
Femoral  artery. 
Exter.  abdominal  ring 
Spine  of  pubis. 
Saphenous  opening. 


Davis.) 


Aneurysm  or  intrathoracic  tumor  may  cause  a  local  bulging  even  though 
it  be  not  directly  in  contact  with  the  chest  wall.  The  widened  inter- 
costal spaces  and  bulging  ribs  of  recent  pleural  exudates,  the  deformity 
of  the  later  stages,  and  the  thoracic  growth  perversions  of  Pott's  disease 
or  spinal  curvature  are  well-recognized  features  of  the  underlying 
lesions. 


452 


THE  THORAX 


Acute  Cellulitis. — Acute  cellulitis  incident  to  trauma,  follicular  abscess, 
osteomyelitis,  and  periadenitis,  secondary  to  peripheral  infection,  occur- 
ring at  times  without  demonstrable  cause,  are  characterized  by  the 
constitutional  symptoms  of  profound  sepsis.  There  is  often  diffuse 
tenderness  and  inspiratory  pain  which  closely  simulates  that  due  to 
pleurisy.  Endocarditis  and  septic  bronchopneumonia  are  common 
complications. 

The  diagnosis  of  this  fortunately  rare  condition  is  based  on  the  local 
seat  of  tenderness,  the  profound  constitutional  symptoms,  with  the 
absence,  at  least  in  the  early  stage,  of  local  signs  of  pleural  involvement. 
Later,  skin  edema  and  fluctuation  are  characteristic  of  suppuration  and 
indicate  its  seat. 


Fig.  330 


Cold,  abscess  of  the  chest  wall  (tuberculous  osteitis).     Painless,  obscurely  fluctuating,  made  tense 
by  coughing  effort.     Overljdng  skin  normal  and  non-adherent. 


Cold  Abscess. — Cold  abscess  of  the  chest  wall  may  be  of  sternal, 
costal,  vertebral,  pleural,  or  mediastinal  origin.  There  is  formed  a 
fluctuating  tumor  which  may  exhibit  impulse  on  coughing  and  which 
may  pulsate. 

The  chest  wall  abscess  of  chronic  vertebral  osteomyelitis  travels 
forward  between  the  ribs;  the  symptoms  of  Pott's  disease  are  usually 
well  marked. 

The  abscess  of  sternal  origin  points  over  the  bone  or  close  to  it;  the 
same  is  true  of  the  cold  abscess  of  the  anterior  mediastinum.  One 
originating  in   the  posterior   mediastinum   may  point  along  the  ribs 


TRAUMATISM  OF  THE  CHEST  453 

or  above  the  clavicle.  If  of  costal  origin  (tuberculous,  post-typhoidal), 
the  abscess  commonly  points  near  its  seat  of  origin,  though  it  may  burrow 
widely.  If  from  the  pleura,  the  associated  signs  of  an  empyema  are 
readily  elicited. 

In  some  instances  cold  abscesses  either  in  the  intercostal  space  or 
in  the  dorsal  region  have  no  connection  with  bone,  the  original  focus 
of  infection  probably  having  healed. 

The  diagnosis  of  cold  abscess,  which  may  be  of  large  size  when  first 
seen,  would  be  suggested  by  distinct  fluctuation.  The  resemblance  to 
lipoma  may  be  so  close  as  to  require  operation  for  differential  diagnosis. 

The  tumor  incident  to  bone  erosion  and  surface  projection  of  an 
aortic  aneurysm  may  present  the  characteristics  of  cold  abscess. 

Traumatism  of  the  Chest. — Concussion. — Concussion  of  the  chest, 
by  which  is  meant  the  effect  produced  by  a  jarring  blow  not  suflSciently 
violent  to  produce  demonstrable  lesions  of  the  thoracic  viscera,  is  evidenced 
by  the  symptoms  of  shock  and  may  be  immediately  fatal.  It  is  not 
infrequently  attended  by  dyspnea  so  pronounced  as  to  occasion  cyanosis, 
the  short,  irregular,  hurried,  painful  breathing  being  characteristic. 
This  condition  can  be  recognized  as  one  independent  of  gross  internal 
lesion  only  by  a  consideration  of  the  relatively  slight  trauma,  at  times 
by  a  knowledge  of  the  patient's  hypersensitiveness  to  physical  impressions, 
and  usually  by  the  rapid  (minutes,  hours)  improvement  of  the  symptoms. 

Spasmodic  stricture  of  the  esophagus  is  an  occasional  sequel  of  chest 
concussion. 

Contusion  of  the  Chest. — Contusion  of  the  chest  is  of  importance  when 
complicated  by  fracture  or  displacement  of  the  bones,  lesions  of  the 
contained  viscera,  or  rupture  of  the  diaphragm.  Fracture  and  luxation 
are  readily  recognized. 

Visceral  lesions  will  be  characterized  by  shock,  and  bleeding  evidenced 
by  constitutional  symptoms  of  hemorrhage. 

Diaphragmatic  rupture  will  be  shown  by  profound  and  persistent 
dyspnea,  displacement  of  the  heart,  and  tympany  and  gurgling  over 
the  seat  of  the  displaced  stomach.  Rupture  of  the  lung  will  be 
suggested  by  hemothorax  or  coughing  up  of  blood,  emphysema  appear- 
insr  first  at  the  base  of  the  neck  if  interstitial,  or  in  the  thoracic  wall 
if  incident  to  lung  wound  by  complicating  fracture. 

Wounds  of  the  Chest. — Wounds  of  the  chest  are  of  importance  in  accord- 
ance with  the  extent  to  which  the  contained  viscera  are  involved.  Injury 
of  the  internal  mammary  or  the  intercostal  artery  may  be  followed  by 
hemothorax  and  the  constitutional  signs  of  progressive  hemorrhage. 
There  is  nearly  always  an  associated  external  bleeding  from  the  wound. 

Wound  of  the  lung  is  characterized  by  shock,  harassing  cough  which 
usually  brings  up  frothy  blood,  dyspnea,  often  severe  pain  which 
may  be  referred  to  the  abdomen,  hemothorax,  and  pneumothorax. 
If  the  wound  be  a  puncture  or  inflicted  by  a  small  cahber  weapon  all 
these  symptoms  may  be  absent. 

Pneumothorax  developing  in  the  presence  of  a  parietal  wound  mechan- 
ically closed  against  the  entrance  of  air  is  a  convincing  sign. 


454  "THE  THORAX 

Diagnosis  as  to  the  seat  of  continued  bleeding,  if  this  be  of  neither  inter- 
costal nor  internal  mammary  origin,  must  be  made  by  opening  the  chest, 
after  due  consideration  of  the  mechanics  of  the  vulnerating  force. 

Complicating  abdominal  wounds  are  common,  implying  necessarily 
injury  to  the  diaphragm. 

Unless  the  distinction  between  a  wound  which  does  and  one  which 
does  not  involve  the  lung  be  fairly  obvious,  it  cannot  be  made  except  by 
operation. 

The  hemothorax  of  chest  wound  may  be  absorbed  very  slowly.  Often 
it  suppurates,  the  symptoms  of  acute  empyema  then  developing. 

Hernia  of  the  lung  follows  as  a  late  sequel  of  wounding  and  at  times  of 
contusion.  It  is  characterized  by  the  appearance  of  a  resonant  crepitant 
projecting  tumor  responding  to  the  influence  of  intrathoracic  tension. 

Wound  of  the  Heart. — Wound  of  the  heart,  if  not  immediately  fatal, 
is  characterized  by  profound  shock,  irregular,  feeble,  rapid  heart  action, 
and  marked  dyspnea.  In  framing  a  diagnosis,  the  probable  depth  and 
direction  of  the  wound,  as  suggested  by  the  vulnerating  agent  and  its 
points  of  entrance  and  of  exit,  are  of  major  importance. 

Blood  effusion  into  the  pericardial  sac  and  hemothorax  are  corrobo- 
rative symptoms  if  they  are  present.  If  the  wound  be  of  sufiicient  size 
to  allow  direct  exploration,  a  positive  diagnosis  can  be  framed.  Other- 
wise, it  must  depend  upon  exploration,  which  would  be  called  for  in  any 
event  by  progressive  bleeding. 

A  wound  of  such  nature  and  direction  as  to  probably  involve  the  heart 
should  be  regarded  as  such  so  far  as  absolute  physical  quietude  of  the 
patient  is  concerned,  since  there  may  be  neither  shock,  hemorrhage, 
nor  other  characteristic  symptoms  immediately  following  heart  lesion. 
Pericardial  blood  effusion  following  a  wound  immediately  or  shortly 
(hours)  or  developing  suddenly  later  (days)  is  almost  pathognomonic 
evidence  of  heart  lesion. 

Fracture  of  the  Sternum. — Fracture  of  the  sternum,  usually  transverse, 
near  the  point  of  junction  of  the  manubrium  and  body,  at  times  a  true 
diastasis,  may  be  caused  by  direct  blow,  in  which  case  the  injury  may 
be  comminuted,  by  muscular  action,  or  by  forced  flexion  or  extension. 
If  there  be  displacement,  the  lower  usually  over-rides  the  upper  fragment 
and  the  diagnosis  is  readily  made.  In  the  absence  of  displacement, 
persistent  tenderness  and  late  ecchymoses  following  an  adequate  cause 
other  than  direct  violence  are  significant.  This  injury  is  a  not  infrequent 
complication  of  vertebral  fracture  dislocation  in  the  cervicodorsal  region. 

Fracture  or  dislocation  of  the  ensiform  process  (rare)  is  characterized 
by  obvious  displacement,  preternatural  mobility,  and  in  a  few  recorded 
cases  by  recurring  attacks  of  pain  and  vomiting. 

Fracture  of  the  Ribs. — Fracture  of  the  ribs,  from  direct  or  indirect 
force  or  muscular  action,  usually  involving  the  fifth  or  eighth,  often  a 
number  of  ribs,  attended,  as  a  rule,  by  little  deformity  and  situated,  even 
when  due  to  indirect  force,  near  the  point  of  application  of  this  force,  is 
characterized  by  pain,  well  localized,  and  greatly  aggravated  by  coughing 
or  deep  breathing,  tenderness,  at  times  crepitus,  and  undue  mobility. 


INFLAMMATIONS  OF  THE  CHEST  455 

Crepitus  with  undue  mobility  may  be  elicited  by  direct  palpation  of  each 
rib;  at  other  times  by  placing  the  thumb  of  each  hand  on  the  extremities 
of  the  suspected  rib  and  making  alternate  or  synchronous  pressure 
against  the  side  of  the  chest  with  the  flat  of  the  handj  while  the  patient 
breathes  deeply  or  coughs. 

The  diagnosis  must  often  be  based,  in  the  absence  of  the  a'-ravs,  on 
the  persistent  pain  and  the  extreme  local  tenderness  to  deep  palpation. 

Fractures  by  muscular  contraction  usually  involve  the  lower  ribs,  and 
may  occur  as  the  result  of  movements  calling  for  no  undue  strain  upon 
the  bones,  such,  for  instance,  as  coughing  or  sneezing,  or  even  turning 
in  bed.  Such  fractures  of  the  ribs  have  not  the  same  significance  as  do 
those  from  inadequate  cause  affecting  the  bones  of  the  extremities 
(bone  tumor),  and  may  be  so  wanting  in  sjTnptonis  that  the  appearance 
of  callus  may  first  call  attention  to  their  existence. 

Fracture  of  the  ribs  may  be  complicated  by  wound  of  the  pleura  or 
lung,  as  evidenced  by  cough,  pleuritic  friction  sounds,  emphysema, 
exceptionally  pneumothorax.  The  superficial  emphysema  is  manifested 
as  a  rapidly  spreading  swelling  which  crepitates  on  palpation  and  may 
extend  over  the  entire  body. 

Hemorrhage  from  an  intercostal  artery  with  bleeding  into  the  pleura 
is  a  rare  complication  of  fracture  of  the  rib. 

Fracture  of  the  Costal  Cartilages. — Fractiu-e  of  the  costal  cartilages, 
commonly  involving  those  of  the  seventh  and  eighth  ribs,  is  usually 
characterized  by  pronounced  lateral  displacement,  at  times  by  over- 
riding, and  is  then  easily  recognized.  Persistent  local  tenderness  and 
pain,  especially  marked  in  movements  calling  the  abdominal  muscles 
into  play  are  the  characteristic  symptoms  in  the  absence  of  displacement. 

Inflammations  of  the  Chest. — The  Skin. — ^The  skin  of  the  thorax 
may  be  the  seat  of  any  of  the  inflammatory  or  neoplastic  lesions  to 
which  this  structure  is  subject.  Acne  and  seborrheic  eruptions  are 
especially  frequent,  and  over  its  lower  lateral  surface  the  first  manifesta- 
tion of  syphilitic  roseola  is  often  seen.  Boils  and  carbuncles,  less 
common  than  on  the  back  of  the  neck,  are  fairly  frequent  on  the  lateral 
chest  wall. 

Osteomyelitis. — Acute  osteomyelitis  of  the  ribs  and  sternum  (^rare)  is 
manifested  by  hyperacute,  constitutional  symptoms  of  infection,  severe 
pain,  local  tenderness,  and  the  rapid  development  of  edema  and  abscess. 
The  diagnosis  should  be  confirmed  by  operation. 

Chronic  osteomyelitis,  usually  tuberculous,  syphilitic,  or  t^'phoidal, 
at  times  an  evidence  of  an  attenuated  or  well-resisted  pyogenic  infec- 
tion, is  characterized  by  the  gradual  (weeks)  development  of  a  moderate 
bone  swelling,  fusiform  if  a  rib  be  involved,  which  is  usually  neither 
markedly  painful  nor  tender.  Softening  and  sinus  formation  are  fairly 
prompt.  The  first  evidence  of  such  an  infection  may  be  a  fluctuating 
tumor  due  to  cold  abscess  extending  toward  the  surface. 

Typhoidal  bone  infection,  is  superficial  and  limited  in  extent.  It 
occurs  during  or  after  convalescence,  exhibits  a  special  predilection  for 
the  ribs,  and  is  placed  on  the  outer  surface  of  the  bone  near  the  osteo- 


456 


THE  THORAX 


cartilaginous  junction.     The  diagnosis  is  based  upon  the  development  of 
one  or  more  fusiform,  slightly  tender  rib  swellings  after  typhoid  fever. 


Fig.  331 


Multiple  osteoperiostitis  ten  months  after  typhoid  fever;  semifluctuating,  non-sensitive  painless 
tumors  attached  to  ribs  covered  by  healthy  skin.    X-ray  negative.    Rapid  (weeks)  formation. 


Tuberculous  osteomyelitis,  which  may  be  either  central  or  peripheral 
in  origin,  may  form  a  cold  abscess  which  may  burrow  wide  of  its  original 
seat.  The  tracing  of  the  resultant  sinuses  may  be  difficult  in  the  absence 
of  palpable  bone  tumor.  It  is  facilitated  by  iodoform  injection  and 
x-ray  pictures.  The  tuberculous  nature  of  the  infection  is  determined  by 
the  tuberculin  test  and  examination  of  the  discharge. 

Such  a  cold  abscess  may  persist  after  healing  of  the  bone  lesion. 

Gumma. — Gumma  of  the  ribs  and  sternum,  fairly  common  seats, 
is  manifested  by  an  indolent  infiltration  which  increases  in  size  more 
rapidly  than  that  of  tuberculosis  and  exhibits  softening  at  an  earlier 
period  (weeks).  Nor  is  there  the  same  tendency  toward  extensive 
sinus  formation,  the  opening  usually  being  direct.  The  diagnosis  is 
based  on  associated  symptoms  and  signs  of  syphilis  and  on  the  effect  of 
appropriate  constitutional  treatment. 

Inflammation  of  the  mediastinum  in  its  acute  form  is  generally  due  to 
an  extension  of  cellulitis  from  the  neck.  Septic  phlebitis  of  the  jugular 
veins,  perforation  of  the  esophagus  or  trachea  by  foreign  bodies  or  as 
a  complication  of  malignant  disease,  suppurating  bronchial  glands    or 


INFLAMMATIONS  OF  THE  CHEST  457 

infections  of  the  pleura,  lung,  pericardium,  ribs,  or  spine  are  among  the 
causes. 

It  is  characterized  by  tenderness  elicited  by  tapping  the  sternum  or 
pressing  deeply  upon  it,  dyspnea,  irregular  feeble  heart  action,  and 
symptoms  of  profound  septic  intoxication. 

The  anterior  mediastinum  is  commonly  involved.  Abscess,  if  it 
extends  peripherally,  appears  to  the  side  of  the  sternum  or  in  the 
epigastric  region. 

Posterior  mediastinitis  is  commonly  accompanied  by  signs  of  irritation 
of  the  spinal  nerve  roots.  The  external  pointing  of  the  abscess  is  in 
the  intercostal  spaces  or  at  the  root  of  the  neck. 

Pericarditis. — ^Inflammation  of  the  pericardium  is  accompanied  by 
effusion.  This  may  be  serous,  formative,  or  purulent.  The  presence 
of  effusion  in  quantity  is  indicated  by  heart  hurry,  often  irregularity  and 
intermission  of  beats,  distant  sounds  and  pronounced  increase  in  the 
area  of  cardiac  dulness,  readily  demonstrable  in  the  absence  of  pleural 
effusion.  The  area  is  usually  pear-shaped,  vi^ith  the  base  downward. 
If  the  effusion  be  large  there  will  be  distinct  bulging  in  the  cardiac  region, 
especially  marked  in  children. 

Hydropericardium  may  occur  as  one  of  the  features  of  a  general  dropsy, 
and  is  then  associated  with  bilateral  pleural  effusion.  After  scarlet 
fever  the  pericardium  may  be  the  only  seat  of  transudate  (Musser). 
Pericardial  effusion  commonly  occurs  in  pneumonia,  rheumatism,  or 
tuberculosis.  It  may  complicate  typhoid  fever,  scarlet  fever,  or  pyogenic 
infection  in  any  of  its  forms. 

The  a'-rays  may  be  helpful  in  diagnosis,  but  should  be  supplemented, 
in  septic  cases  with  local  symptoms,  by  exploratory  incision. 

Adherent  'pericardium  may  follow  an  acute  pericarditis  or  may  develop 
insidiously  in  the  course  of  tuberculosis.  It  is  characterized  by  systolic 
retraction  of  the  interspaces  most  marked  at  the  position  of  the  apex 
beat  and  synchronous  with  systolic  shock,  outward  displacement  of  the 
apex,  increased  area  of  impulse,  diastolic  shock,  collapse  of  the  cervical 
veins  during  diastole,  weakening  of  the  pulse  during  inspiration  and 
upward  extension  of  the  area  of  cardiac  dulness  not  modified  by  full 
inspiration.  There  are  often  signs  of  an  associated  pleurisy.  These 
findings  are  associated  with  the  subjective  symptoms  of  either  dilatation 
or  h}'pertrophy  (Musser). 

Pleural  Effusions. — Pleural  effusions,  with  the  exception  of  those  trans- 
udates due  to  venous  stasis  or  blood  dyscrasia,  which  are  usually  bi- 
lateral and  accompanied  by  ascites,  are  generally  secondary  to  abnormal 
conditions  of  the  organs  invested  by  the  pleura  or  of  the  inner  portion 
of  the  walls  of  the  thorax. 

A  serous  pleural  effusion  is  a  common  accompaniment  of  subphrenic 
and  perinephric  abscess,  and  is  a  symptom  which  may  divert  attention 
from  a  spinal  osteomyelitis. 

The  effusion  may  be  serous,  fibrinous,  or  suppurative;  may  be  acute 
in  onset  and  course  and  characterized  by  well-marked  symptoms,  or 
may  be  chronic  from  the  first. 


458  THE  THORAX 

The  serous  effusion  becomes  of  surgical  importance  only  when  it 
markedly  interferes  with  either  respiration  or  circulation,  or  both. 

Pain,  non-productive,  harassing  cough,  hurried  breathing,  moderate 
fever,  dyspnea  on  slight  exertion  are  the  characteristic  symptoms,  and  are 
corroborated  by  percussion  dulness  or  flatness,  absence  of  breath  sounds 
and  vocal  fremitus,  and  displacement  of  the  heart.  There  is  always,  if 
the  effusion  be  of  considerable  size,  diminished  excursion  of  the  chest 
wall,  and  enlargement  of  the  affected  side.  Such  a  condition,  developing 
in  the  absence  of  acute  inflammatory  affection  of  the  lungs,  chest  walls, 
or  lower  surface  of  the  diaphragm,  and  not  incident  to  an  acute  systemic 
infection,  is  usually  tuberculous. 

Empyema  may  follow  wounds  of  the  pleura  or  lung.  It  is  a  common 
sequel  of  pleuropneumonia,  is  not  infrequent  in  tuberculosis,  and  repre- 
sents the  usual  direction  of  extension  of  the  perinephric  abscess. 

In  addition  to  the  symptoms  common  to  the  pleuritic  exudate  those 
of  septic  absorption  are  usually  pronounced.  The  nature  of  the 
infecting  organism  can  be  determined  by  removal  and  bacteriological 
examination  of  the  purulent  contents. 

The  purulent  empyema  of  tuberculous  origin  may  be  latent.  It  is 
not  infrequently  complicated  by  pneumothorax. 

Chylothorax,  due  to  trauma  of  the  thoracic  duct  or  its  obstruction 
by  tumor,  exhibits  the  symptoms  of  a  pleural  effusion  and  is  recognized 
by  the  presence  of  a  cream-like  fluid  withdrawn  by  puncture. 

Exploratory  puncture  of  the  chest  is  accomplished  by  means  of  a 
syringe  of  adequate  capacity  with  a  needle  at  least  four  inches  long, 
with  a  short  point,  and  of  sufficient  caliber  to  evacuate  by  suction  a 
thick  fluid. 

The  points  of  election  for  puncture  are  the  sixth  interspace  in  the 
axillary  line,  the  eighth  interspace  in  the  scapular  line,  or  at  such  a 
position  as  the  conditions  present  indicate.  The  skin  is  cleansed, 
anesthetized,  and  cut  through  by  a  stab  with  a  sharp  pointed  tenotome 
to  the  subcutaneous  fat,  thus  avoiding  the  danger  of  carrying  skin  infec- 
tion to  the  deeper  parts  and  enabling  the  surgeon  to  feel  the  lessened 
resistance  to  the  needle  point  encountered  when  it  has  entered  the 
pleural  cavity.  The  needle,  attached  to  the  syringe,  is  then  inserted, 
with  the  finger  pressed  against  it  at  a  distance  from  its  point  equal  to 
the  probable  thickness  of  the  chest  wall  in  order  to  prevent  it  from 
going  in  too  far,  close  to  the  upper  border  of  the  rib  into  the  chest 
cavity.  The  piston  is  slowly  withdrawn;  if  no  fluid  is  obtained  the 
needle  is  slowly  pushed  farther  in.  If  the  first  puncture  is  negative, 
others  should  be  made.  A  small  amount  of  fluid  suffices  for  the  objects 
of  an  exploratory  puncture.  The  opening  is  closed  with  collodion 
unless  operation  is  to  follow  at  once. 

Fluid  thus  aspirated  is  examined  for  its  cellular  contents  and  the 
particular  form  of  infection  present,  a  portion  being  saved  in  a  sterile 
vessel  for  culture  and  inoculation  should  this  seem  needful.  Non- 
traumatic, blood-stained  effusion  is  suggestive  of  malignant  dis- 
ease. 


INFLAMMATIONS  OF  THE  CHEST  459 

Abscess  of  the  Lung. — Abscess  of  the  lung  usually  follows  pneumonia, 
and  is  suggested  by  a  continuance  and  exacerbation  of  the  symptoms 
of  general  infection  beyond  the  time  for  resolution,  without  demonstrable 
evidences  of  further  extension  of  the  pneumonic  process.  Marked 
daily  variation  in  temperature  and,  particularly,  recurring  attacks  of 
chill,  fever,  and  sweat  are  characteristic. 

If  the  abscess  be  near  the  lung  surface,  circumscribed  percussion 
dulness  is  the  sign  of  major  import,  associated  with  the  usual  signs  of 
consolidation.  If,  in  the  course  of  these  symptoms,  there  be  a  sudden, 
profuse,  purulent  expectoration,  and  the  signs  of  local  consolidation  are 
succeeded  by  those  of  cavity  formation,  the  diagnosis  is  assured.  The 
ic-rays  are  helpful  in  establishing  the  presence  of  an  abscess  and  in  local- 
izing it. 

Suppurating  bronchial  glands,  septic  emboli,  foreign  bodies,  extension 
of  suppuration  from  the  postperitoneal  structures  or  the  thoracic  parietes 
are  occasional  causes  of  lung  abscess. 

Gangrene  of  the  Lung. — Gangrene  of  the  lung,  usually  a  sequel  of 
pneumonia,  is  attended  by  symptoms  similar  to  those  of  abscess.  The 
constitutional  condition  is  one  of  profound  sepsis.  The  expectoration  is 
extremely  foul. 

Bronchiectasis. — Bronchiectasis,  often  associated  with  tuberculosis,  and 
observed  in  alcoholics  and  diabetics,  may  closely  simulate  abscess.  It 
is  slow  in  onset,  and  the  constitutional  symptoms  are  those  of  chronic 
sepsis.  In  addition  to  cough,  often  altered  in  severity  by  position,  there 
is  a  profuse  purulent  expectoration  which  may  be  almost  odorless  or 
extremely  foul.  It  may  contain  blood,  sometimes  a  considerable  quantity 
of  it.  Constitutional  symptoms  are  not  in  proportion  to  the  amount  of 
discharge. 

Localized  Tuberculosis. — Localized  tuberculosis  of  the  lung  may  be 
considered  as  a  surgical  affection  when  an  inadequately  drained  cavity 
is  formed.  The  symptoms  are  those  of  tuberculous  infection,  cavity, 
sepsis,  and  deterioration  in  health  more  pronounced  than  would  be 
usually  noted  as  a  consequence  of  a  limited  process. 

Echinococcus. — An  echinococcus  cyst,  causing  the  symptoms  of  me- 
chanical displacement,  including  shortness  of  breath,  pain,  dulness  on 
percussion,  and  absence  of  respiratory  murmur,  is  rarely  diagnosticated 
as  such  without  exploratory  puncture. 

Actinomycosis. — Actinomycosis  (rare)  in  its  primary  form  is  character- 
ized by  the  symptoms  of  chronic  pulmonary  tuberculosis.  Pleural 
effusion  may  be  the  first  symptom  noted. 

In  its  ultimate  development  hard  infiltration  of  the  chest  wall  with 
sinus  formation  may  suggest  malignant  growth.  The  diagnosis  from 
tuberculosis  can  be  made  only  by  the  continued  absence  of  tubercle 
bacilli  from  the  sputum  and  the  negative  evidence  of  the  tuberculin  test. 
It  is  made  occasionally  by  finding  the  ray  fungus. 

Syphilis  of  the  Lung. — Syphilis  of  the  lung,  developing  in  its  tertiary 
stage  as  a  diffuse  or  circumscribed  infiltration,  exhibits  the  symptoms 
and  local  findings  of  pulmonary  tuberculosis,  nor  can  a  differential  diag- 


460 


THE  THORAX 


nosis  be  made  except  by  the  persistent  absence  of  the  tubercle  bacillus, 
the  presence  of  other  lesions  or  signs  of  syphilis,  a  history  of  spirochetal 
infection,  and  the  result  of  efficient  constitutional  treatment. 

Tumors  of  the  Thorax. — Lymphangiomata  and  hemangiomata,  sub- 
ject to  rapid  enlargement,  moles  exhibiting  malignant  degeneration, 
and  keloid,  are  congenital  tumors  common  in  the  skin  of  the  chest. 
Lipoma  and  fibroma  are  frequently  seen  here,  the  former  simulating 
at  times  cold  abscess,  but  exhibiting  typical  lobulations  and  freedom 
from  deep  attachment,  except  when  it  is  of  subpleural  origin,  the  latter 
of  slow  growth  and  dense  consistency,  indistinguishable  in  its  beginning 
from  sarcoma. 


Fig.  332 


Subcutaneous  lipoma  of  back.  Sharply  circumscribed  tumor  movable  beneath  skin  and  on 
underlying  tissues.  Uniform  soft  consistency  simulating  fluctuation.  Skin  dimples  on  being 
made  tense.      (Carnett.) 

Subpleural  lipoma  may  project,  forming  an  external  tumor,  soft  and 
lobulated,  lying  below  the  muscles  and  apparently  adherent  to  the  chest 
wall.  The  major  part  of  it  may  be  intrathoracic.  Mediastinal  lipoma 
may  act  precisely  the  same  way.     These  tumors  at  times  grow  rapidly. 

Sarcoma  of  the  soft  parts,  rare,  except  in  the  region  of  the  shoulder 
as  an  extension  from  the  breast  or  as  a  malignant  degeneration  of  a 
congenital  skin  lesion,  is  characterized  by  the  rapid  growth  of  an  appar- 
ently causeless  tumor.  It  should  be  diagnosticated  by  complete  removal 
and  microscopic  examination. 

Carcinoma  of  the  chest  wall  is  usually  an  extension  from  the  breast, 


TUMORS  OF  THE  THORAX  461 

occasionally  in  the  form  of  a  rapid  (weeks,  months),  widely  spreading, 
nodular  infiltration  (cancer  en  cuirasse)  involving  a  large  surface. 

Epithelioma  forms  a  chronic  slowly  growing  ulcer   which  must  be 
diagnosticated  by  excision. 

Fig.  333 


Hernia  through  linea  alba.  Sudden  onset  during  heavy  lifting;  twenty  years'  duration;  expansile 
impulse  on  coughing;  incomplete  reduction  on  lying  down  or  by  manipulation;  small,  irreducible 
nodule,  probably  omentiim;  ring  admits  tip  of  thimab.     (Carnett.) 

Tumor  of  the  Ribs  and  Sternum. — The  bone  tumors  of  the  thorax  are 
usually  sarcomata. 

Osteoma  and  chondroma,  growing  from  the  region  of  the  costochondral 
junction  of  the  ribs  and  from  that  of  the  manubrium  and  body  of  the 
sternum,  exhibit,  if  palpable,  characteristic  hardness,  and  in  the  case 
of  osteoma,  slow  growth.  The  diagnosis  should  be  made  by  the  x-rays 
or  by  exploration. 

Sarcoma,  not  infrequently  post-traumatic,  is  characterized  by  its 
rapid  growth  and  by  the  a:;-ray  findings.  Pressure  pain  may  be  severe. 
The  distinction  from  a  chronic  osteomyelitis  may,  in  the  early  stages 
of    the   affection,  be   impossible;   later,  the   large  size   without   sinus 


462  THE  THORAX 

formation  or  tendency  thereto  is  characteristic.  The  inward  growth  is 
commonly  much  greater  than  would  be  suggested  by  external  examina- 
tion. The  diagnosis  should  be  made  by  early  complete  removal  of 
a  bone  tumor  which  is  not  obviously  benign. 

Tumor  of  the  Mediastinum. — Exceptionally  benign  (fibroma,  lipoma) 
mediastinal  tumor  is  usually  of  lymphatic  origin,  malignant  and  second- 
ary to  cancer  of  the  breast,  thyroid,  lung,  pleura,  or  esophagus. 

Pressure  symptoms,  bulging  of  the  chest  wall,  the  development  of  a 
palpable  tumor  are  the  characteristic  features  of  all  mediastinal  tumors, 
malignancy  being  suggested  by  rapid  progression. 

The  pressure  symptoms  are  radiating  pain,  both  deep  and  localized; 
harassing,  futile  cough;  dyspnea,  often  with  stridor;  pleural  effusion; 
venous  congestion  of  the  head,  chest,  and  upper  extremities,  with 
occasionally  chest  edema;  hoarseness  or  loss  of  voice;  displacement  of 
the  heart,  displacement  of  the  trachea,  difficulty  in  swallowing,  and 
rapid  emaciation. 

Percussion  dulness  will  be  elicited  if  the  tumor  lie  near  the  sternum. 
Palpation  deep  in  the  suprasternal  notch  may  enable  the  tumor  to  be 
felt.  Lymphatic  involvement  of  the  lower  cervical  group  of  glands  is  a 
corroborative  symptom.  These  tumors  may  pulsate  and  may  closely 
simulate  aneurysm.     The  a:-rays  may  be  helpful. 

Tumor  of  the  Pleura. — Tumor  of  the  pleura,  usually  secondary 
endothelioma,  if  primary,  is  characterized  by  a  pleuritic  exudate  and 
a  profound  deterioration  in  general  health.  It  is  usually  regarded  as 
tuberculous  until  aspiration  reveals  a  blood-stained  fluid.  Positive 
diagnosis  is  made  by  direct  exploration  through  an  incision. 

Tumor  of  the  lung,  rare  except  in  its  secondary  form,  is  characterized 
by  the  symptoms  of  circumscribed  consolidation  without  mucopurulent 
expectoration.  There  is  commonly  an  associated  pleural  exudate,  a 
profound  cachexia,  and  later  there  may  be  bloody  expectoration.  The 
a;-rays  may  be  helpful  in  diagnosis. 

Aneurysm  of  the  Aorta.— Aneurysm  of  the  aorta,  usually  from  the 
ascending  portion  of  the  arch,  if  it  produce  symptoms,  is  characterized 
by  those  of  pressure,  such  as  are  common  to  mediastinal  tumor,  but  with 
dyspnea  and  difficulty  in  swallowing  more  marked,  and  not  infrequently 
by  tracheal  tug.  When  the  growth  reaches  sufficient  size  to  form  a 
palpable  external  tumor,  the  thrill  and  expansile  pulse  are  usually 
characteristic.     These  symptoms  may  be  absent. 

The  occasional  difficulties  of  diagnosis  are  exemplified  by  the  circum- 
stance that  such  aneurysms  have  been  opened  because  of  the  diagnosis 
of  cold  abscess. 

The  a:-rays  are  often  diagnostic.  Aspiration  should  be  employed  in 
case  of  doubt. 

THE  BREAST. 

In  the  superficial  layer  of  fatty  tissue  overlying  the  muscles  of  the 
anterior  chest  wall  is  the  mammary  gland  made  up  of  from  fourteen 


THE  BREAST  463 

to  twenty  lobes,  each  provided  with  a  duct  opening  on  the  surface  of 
the  nipple,  exhibiting  a  narrowing  near  its  orifice,  and  a  dilatation  be- 
neath the  areola.  These  lobes  are  bound  together  by  a  fibrous  invest- 
ment which  sends  numerous  extensions  to  the  skin  and  which  intimately 
connects  the  latter  with  the  deep  fascia  at  the  lower  margin  of  the  gland. 

Surrounding  the  breast  there  is  an  abundant  fatty  investment  which 
penetrates  between  the  lobes  and  which  mainly  gives  the  gland  its  full, 
rounded  shape.  The  breast  is  loosely  attached  to  the  pectoral  fascia, 
and,  though  in  the  main  disk-shaped,  exhibits  aberrant  extensions. 
The  one  toward  the  axilla  is  fairly  constant  and  may  be  so  widely 
separated  from  the  rest  of  the  gland  as  to  suggest  a  distinct  tumor. 

Two  peripheral  extensions  are  usually  found  along  the  inner  margin 
of  the  breast  and  the  gland  structure  at  times  dips  into  the  substance 
of  the  pectoral  muscle. 

The  small  nodules  in  the  thin,  pigmented  skin  of  the  areola  which 
develop  at  puberty  are  sebaceous  glands. 

The  arterial  supply  is  from  the  internal  mammary  through  perforating 
branches,  from  the  axillary  through  the  long  thoracic  and  acromio- 
thoracic,  and  from  the  intercostals. 

The  venous  return  is  through  the  axillary  and  internal  mammary 
vessels. 

The  superficial  lymphatic  vessels  pass  from  the  overlying  skin  of  the 
breast,  with  the  exception  of  that  covering  the  nipple  and  areola,  into  the 
thoracic  group  of  axillary  glands;  these  vessels  communicate  freely  with 
those  of  the  other  breast.  The  lymphatics  of  the  nipple,  areola,  and 
glandular  tissue  pass  to  the  upper  inner  group  of  the  axillary  glands, 
through  the  substance  of  the  pectoralis  major  muscle  to  the  retropectoral 
glands,  and  to  the  group  lying  below  and  above  the  clavicle  and  through 
the  intercostal  spaces  to  the  retrosternal  glands.  All  the  axillary  gland 
groups  intercommunicate. 

The  breast  remains  rudimentary  in  both  sexes  until  the  age  of  puberty, 
when  in  the  woman  it  attains  its  physiological  development.  It  then 
forms  a  soft,  semiglobular,  movable  mass,  which,  with  its  outlying  nodules, 
can  usually  be  distinguished  from  the  investing  fat  by  gentle  palpation, 
giving  to  the  examining  hand  a  sense  of  density  greater  than  that  of  the 
surrounding  fat  and  of  fine,  soft  lobulation. 

Palpation  of  the  mammary  gland  is  best  effected  by  placing  the  patient 
in  the  dorsal  decubitus,  with  the  hand  of  the  side  to  be  examined  carried 
to  the  back  of  the  neck.  The  skin  should  be  freely  movable  over  the 
gland  at  all  points  except  at  the  areola  and  the  submammary  fold. 
Nodules  or  indurations  are  detected  both  by  grasping  the  substance  of 
the  gland  transversely  and  vertically  between  the  forefingers  of  the  two 
hands,  by  palpating  portions  of  it  between  the  finger  and  thumb  of 
one  hand,  and  finally  by  a  pressing  rolling  motion  of  the  fingers  com- 
pressing the  gland  against  the  pectoral  and  serratus  muscles. 

Examination  of  the  axilla  for  enlarged  glands  is  facilitated  by  the  patient 
placing  her  hand  on  the  mnbilicus.  The  examining  finger  should  be 
carried  to  the  deepest  part  of  the  arm  pit,  and  should  take  in  not  only 


464  THE  THORAX 

its  thoracic  aspect  but  the  inner  and  lower  surfaces  of  its  anterior  wall. 
Moreover,  the  supraclavicular  and  infraclavicular  regions  should  be 
carefully  palpated. 

General  Symptomatology. — ^The  most  conspicuous  and  significant 
symptom  of  affections  of  the  breast  is  swelling.  This  may  be  diffuse 
or  localized,  and  may  or  may  not  be  accompanied  by  symptoms  of  acute 
inflammation. 

The  affections  which  are  characterized  mainly  by  increased  size  of 
the  entire  breast,  with  inflammatory  phenomena  slight  or  wanting,  are 
hypertrophy;  the  rapid  gland  growth  incident  to  puberty,  pregnancy, 
and  lactation;  mastitis  of  the  newly  born;  the  congestive  enlargement 
in  women  at  beginning  of  sexual  life;  and,  exceptionally,  infiltrating 
carcinoma. 

Affections  mainly  characterized  by  acute  or  subacute  inflammatory 
phenomena  are  furuncle,  supramammary  and  submammary  abscess, 
suppurative  mastitis,  and  diffuse  carcinomatosis. 

Ulcerating  lesions  which  begin  superficially  are  fissure  or  erosion, 
chancre,  mucous  patch,  eczema,  Paget's  disease,  and  epithelioma. 

Affections  which  begin  as  circumscribed  tumors  with  inflammatory 
symptoms  slight  or  absent  are  neoplasms,  solid  or  cystic,  benign  or 
malignant,  tuberculoma,  cold  abscess  (rare),  and  actinomycosis  (rare). 

The  tuberculoma  and  gumma  soften  and  ulcerate  through  the  skin 
before  they  reach  the  size  of  a  fist  (two  to  six  months);  ulceration  of 
malignant  tumors  does  not  occur  until  they  reach  much  larger  size. 

The  axillary  glands  are  enlarged  rapidly  (days)  in  consequence  of  the 
congestion  and  hyperdevelopment  of  pregnancy,  in  all  forms  of  acute 
infection  of  the  nipple,  breast,  and  surrounding  fat,  and  in  chancre. 
They  enlarge  slowly  (weeks  or  months)  in  tuberculosis,  cold  abscess,  and 
carcinoma,  exhibiting  in  the  former  case  a  tendency  to  soften  when  they 
have  reached  the  size  of  the  thumb,  often  becoming  converted  into  sacks 
of  pus.  The  cancerous  lymphatic  enlargement  is  hard,  and  in  the  early 
stages  multiple  and  discrete. 

Discharge  from  the  nipple  other  than  milk  occurs  as  an  expression 
of  vicarious  menstruation,  of  acute  and  chronic  mastitis,  and  of  both 
benign  and  malignant  growths.  A  blood-stained  discharge  is  in  itself 
not  indicative  of  malignancy. 

Malformations. — ^The  breast  may  be  absent  (amastia)  or  aberrant 
and  supernumerary  (polymastia).  It  may  be  atrophied  entirely  or  in  part 
or  hypertrophied.  The  nipple  may  be  absent  (athelia)  or  aberrant  and 
supernumerary  (polythelia).  It  may  be  extremely  short,  or  retracted 
and  umbilicated. 

Congenital  Malformations. — ^Amastia  and  athelia,  or  absence  of  breast 
and  nipple,  may  be  unilateral  or  bilateral.  This  deformity  is  extremely 
rare,  and  has  been  noted  in  association  with  congenital  defects  of  the 
thorax  and  absence  of  the  ovary  of  the  affected  side. 

Polymastia  and  polythelia,  or  supernumerary  breast  and  nipple,  are 
fairly  common  deformities,  toward  the  development  of  which  heredity 
is  a  distinct  predisposing  factor.     The  misplaced  glands  are  usually 


THE  BREAST  455 

small  and  functionless  and  are  found  in  the  anterolateral  thoracic  regions, 
though  thev  have  been  noted  on  the  face,  thigh,  external  genitals,  shoulder, 
and  in  a  number  of  instances  in  the  axilla.  The  anomaly  is  commonest 
in  males.  Lichtenstern  found  3  out  of  72  multimammiferous  women 
who  bore  twins. 

The  short  or  umbilicated  nipple  due  to  malformation  or  the  extreme 
invagination  noted  at  times  in  the  fatty,  pendulous  breast,  must  be 
distinguished  from  retraction  which  is  a  characteristic  sign  of  carci- 
noma and  which  develops  in  the  course  of  months  in  a  nipple  of  pre- 
vious proper  conformation. 

The  diagnosis  of  supernumerary  breasts  and  nipples  is  either  obvious 
or  possible  only  by  excision  and  microscopic  examination.  A  super- 
numerary breast  without  a  nipple  resembles  closely  a  fatty  tumor,  and 
supernumerary  nipples  without  underlying  breasts  may  simulate  pig- 
mented warts  and  nevi. 

Atrophy  of  the  Breast. — x\trophy  of  the  breast,  rarely  complete,  attributed 
to  the  mastitis  occiuring  shortly  after  birth,  may  be  unilateral  or  bilateral, 
and  is  often  associated  with  genital  infantilism.  The  overlying  fatty 
tissue  may  conceal  the  deformity. 

There  is  no  enlargement  at  puberty  or  milk  secretion  after  gestation. 

Hypertrophy  of  the  Breast. — Hypertrophy  of  the  breast  affects  both 
sexes  and  is  characterized  by  a  rapid  and  abnormal  growth  of  the  entire 
gland.  It  exhibits  a  predilection  for  young  girls  after  puberty  and  for 
women  in  the  early  months  of  pregnancy,  appearing  as  a  rapid,  painless 
enlargement  of  one  or  both  breasts  so  symmetrical  as  to  cause  a  feelino- 
of  satisfaction,  which  in  the  course  of  days  or  weeks  is  changed  to  one 
of  alarm  as  the  growth  becomes  a  deformity.  It  progresses  rapidly, 
reaches  enormous  dimensions,  is  attended  by  systemic  depression,  and 
is  uninfluenced  by  medical  treatment.  That  form  which  develops  during 
the  early  part  of  gestation  usually  disappears  after  delivery,  though  the 
child  is  likely  to  be  puny. 

The  diagnosis  of  hypertrophy  of  the  breast  is  based  upon  the  rapid 
symmetrical  progressive  increase  in  the  size  of  the  entire  gland  without 
inflammatory  phenomena,  localized  induration  or  skin  adhesion. 

Hypertrophy  of  the  male  breast  (gynecomastia)  is  usually  bilateral 
and  moderate  in  development,  forming  a  globular  projecting  mass  such 
as  is  normal  to  a  young,  unmarried  woman,  readily  distinguishable  upon 
palpation  from  the  fat  of  this  region. 

Though  often  associated  with  genital  defects,  it  occurs  in  healthy, 
sexually  developed,  potent  men,  the  breast  reaching  its  abnormal  size 
at  or  shortly  after  puberty.  It  may  follow  the  destruction  or  removal 
of  the  testes  between  the  twentieth  and  the  twenty-fifth  year  of  life. 
Neither  the  completely  grown  adult  nor  the  infant  exliibits  gyneco- 
mastia as  a  result  of  castration. 

Nipple  and  Areola. — Dilatation  of  the  galactophorous  ducts  may 
sometimes  be  seen  as  a  soft,  club-shaped  swelling,  lying  just  beneath 
the  skin.     Papilloma  of  the  duct  characterized  by  a  bloody  discharge 
has  been  felt  as  a  slightly  movable  nodule. 
30 


466  THE  THORAX 

Furuncle. — Furuncle  of  the  areola,  commonest  in  nursing  women, 
develops  in  the  sebaceous  glands,  forming  one  or  more  small,  superficial, 
painful,  tender,  inflamed,  hard  nodules  which  shortly  soften  and  dis- 
charge.    By  confluence  they  may  form  short  sinuses  beneath  the  skin. 

Fissures  of  the  Nipple. — Fissures  of  the  nipple,  predisposed  to  by 
vices  of  conformation  and  uncleanliness,  are  caused  by  repeated  trau- 
matism and  infection,  hence  are  common  in  women  who  are  nursing 
babies  with  sore  mouths.  They  are  often  multiple  and  may  be  deeply 
destructive. 

Chancre  of  the  Nipple  and  Areola. — This  is  often  bilateral  and  multiple, 
and  may  exactly  simulate  fissure.  Axillary  adenopathy,  more  indolent 
and  hyperplastic  in  type  than  that  characteristic  of  simple  fissure, 
associated  with  an  indurated  ulcerating  lesion  which  does  not  respond 
to  local  treatment,  should  excite  a  suspicion  of  syphilis.  The  diagnosis 
is  made  by  finding  the  Treponema  pallidum. 

Eczema. — Eczema  forms  a  red,  raw,  irregular,  crusted  patch  of  excori- 
ated skin  about  the  nipple,  which  yields  to  the  treatment  appropriate 
to  this  condition  when  it  appears  elsewhere. 

Fig.  334 


Paget's  disease  of  the  nipple;  long  duration;  followed  by  carcinoma  of  the  breast.     (Hartzell.) 

Paget's  Disease. — Paget's  disease  closely  resembles  eczema,  but  differs 
from  it  in  being  rebellious  to  treatment.  It  is  followed  by  carcinoma. 
The  diagnosis  is  based  on  persistence  and  slow  extension  in  spite  of 
careful  treatment,  and  finally  on  excision  and  microscopic  examination. 

Epithelioma  of  the  Nipple  and  Areola. — This  is  characterized  by  the 
slow  formation  (months)  in  women  past  middle  age  of  an  indurated, 
jagged,  destructive  ulceration  accompanied  by  enlargement  of  the  axillary 
glands.     The  diagnosis  should  be  made  by  immediate  excision. 

Supramammary  and  Submammary  Abscess. — Acute  supramam- 
mary  abscess  develops  commonly  in  the  fatty  tissue  lying  about  the 
lower  segment  of  the  gland,  especially  in  those  whose  breasts  are  large 
and  pendulous.  The  symptoms  are  acute  and  obvious,  the  rapid  skin 
involvement  showing  the  superficial  nature  of  the  infection. 


THE  BREAST  467 

Acute  submammary  abscesses  are  always  secondary  to  suppurative 
mastitis,  systemic  infection,  or  traumatism.  The  loose,  cellular  tissue 
at  this  point  favors  the  rapid  accumulation  of  pus  which  thrusts  the 
whole  breast  forward. 

The  diagnosis  is  based  upon  the  presence  of  an  adequate  cause 
(mastitis),  the  forward  projection  of  the  entire  breast,  the  finding  of  an 
edematous  collar  about  it,  glandular  involvement,  and  the  constitutional 
and  blood  symptoms  of  infection. 

Chronic  submammary  abscess,  usually  secondary  to  caries  of  the  ribs 
or  sternum,  or  extension  of  pus  from  the  mediastinum,  forms  a  deeply 
placed  tumor  not  movable  on  the  chest  wall.  This  fact  should  suggest 
the  diagnosis,  though  it  is  not  usually  determined  until  operation. 

Mastitis. — Swelling  of  the  breast,  with  slight  heat  and  tenderness, 
and  at  times  an  associated  transitory  adenopathy,  is  observed  shortly 
after  birth,  at  puberty  in  both  sexes,  and  in  the  female  at  the  beginning 
of  sexual  life  and  during  pregnancy  and  lactation. 

The  mastitis  of  infancy  develops  in  both  sexes  a  few  days  after  birth, 
is  transitory,  and  is  attended  by  a  milky  discharge  from  the  nipple. 
Exceptionally  abscesses  form,  or  the  inflammation,  becoming  chronic, 
may  cause  atrophy. 

The  mastitis  of  puberty  (both  sexes)  may  be  attended  by  a  serous  dis- 
charge from  the  nipple.  It  subsides  within  a  week.  Exceptionally 
abscess  forms;  this  is  likely  to  be  superficial  and  single. 

With  the  assumption  of  sexual  life  the  breasts  of  women  swell  and 
become  tender,  often  vaguely  nodular.  This  is  a  transitory  condition 
not  leading  to  infection. 

Lactation  mastitis  is  commonest  in  primipara  who  nurse  their 
children,  and  develops,  as  a  rule,  in  the  first  months  after  childbirth. 

The  essential  predisposing  conditions  are  overdistention  of  the  breast 
with  its  normal  secretion,  exposure  to  cold,  and  infection,  often  from  a 
fissured  nipple. 

Lactation  mastitis  may  appear  in  the  form  of  a  tender  induration 
which  may  subside  promptly,  may  quickly  develop  the  symptoms  of 
acute  suppuration,  or  may  persist  and  slowly  enlarge  and  soften,  forming 
a  chronic  abscess. 

If  the  primary  induration  does  not  subside,  it  usually  becomes  acutely 
painful,  the  overlying  skin  is  edematous,  the  constitutional  and  blood 
symptoms  of  infection  are  present,  and  fluctuation  soon  develops. 

Chronic  mastitis  is  characterized  by  persistent  induration  which  may 
form  an  indolent  abscess  or  may  undergo  malignant  degeneration. 

The  diagnosis  as  to  the  nature  of  a  persistent  infiltration  or  a  fluctu- 
ating tumor  of  the  breast  developing  during  lactation  should  be  made 
by  exploratory  operation. 

Acute  puerperal  mastitis  may  be  total  (rare).  This  form  of  infection 
is  characterized  by  sudden,  violent,  overwhelming  inflammation  of  the 
entire  breast.  The  constitutional  symptoms  are  those  of  profound 
toxemia.  It  may  terminate  in  gangrene  characterized  by  dusky  dis- 
coloration of  the  skin,  vesication,  and  extrusion  of  large  sloughs. 


468  THE  THORAX 

Tuberculous  Mastitis. — Tuberculous  mastitis  in  about  half  the  reported 
cases  has  developed  in  young  women  without  other  tuberculous  lesions. 
It  is  at  times  secondary  to  tuberculous  axillary  lymphadenitis.  It  is  char- 
acterized by  a  slowly  growing,  vaguely  outlined,  painless,  at  first  non- 
inflammatory, dense  induration,  usually  in  the  central  zone  of  the  breast. 
In  about  three  months  this  tumor,  having  reached  the  size  of  a  child's 
fist,  fluctuates  and  ulcerates  through  the  skin  which  is  undermined, 
but  not  infiltrated  and  adherent.  The  axillary  glands  are  enlarged  early 
(one  month)  and  are  more  inflammatory  in  type  than  is  the  involvement 
of  carcinoma.  They  may  soften  and  discharge  cheesy  pus  while  the 
breast  tumor  is  still  forming. 

Mammary  tuberculosis  might  be  suggested  by  the  presence  of  tubercu- 
losis elsewhere,  and  particularly  of  obviously  tuberculous  glands  in  the 
axilla.  It  begins  precisely  as  does  cancer.  Hence  its  true  nature  should 
be  determined  by  immediate  excision  and  examination. 

Syphilitic  Mastitis  (rare). — Gumma  of  the  Breast. — This  is  often  bi- 
lateral, forms  a  hard,  painless,  rounded  tumor,  unattended  by  either 
adenopathy  or  systemic  symptoms.  In  one  to  three  months,  and  before 
it  has  reached  a  size  greater  than  that  of  an  egg,  it  softens  and  ulcerates, 
forming  a  typical,  punched-out,  non-proliferating  ulcer.  Axillary 
adenopathy  may  now  develop  from  mixed  infection. 

In  its  early  stages  this  infiltration  exactly  simulates  malignant  growth. 
The  differential  diagnosis  must  be  by  excision  and  microscopic  examina- 
tion, though  a  clear  history  of  syphilis  with  associated  manifestations  of 
this  disease  might  suggest  the  therapeutic  test  of  mercury  and  the  iodides. 

Hydatid  Cyst. — -Hydatid  cyst  (very  rare)  forms  a  round,  hard  tumor, 
which  in  the  course  of  two  years  is  prone  to  inflammation  and  suppu- 
ration.    The  diagnosis  can  be  made  only  by  excision. 

Sebaceous  Cyst. — Sebaceous  cyst  develops  in  the  skin,  forming  a 
globular,  finally  disk-shaped,  moderately  hard  tumor,  superficially  placed, 
slow  in  growth  (years),  and  discharging  from  its  central  aperture  on 
firm  pressure  or  through  a  puncture  the  characteristic  semisolid,  cheesy 
substance.     It  has  been  mistaken  for  carcinoma. 

Galactocele. — Galactocele  developing  in  the  lactating  breast  is  char- 
acterized by  the  rapid  formation  of  a  cyst  without  infiammatory 
phenomena.  Pressure  upon  the  cyst  may  cause  milk  to  flow  from 
the  nipple.  The  condition  may  become  chronic,  the  contents  of  the 
cyst  then  becoming  thick  and  oily. 

Tumors. — Since  tumor  of  the  breast  is  usually  painless,  its  presence 
is  often  not  suspected  by  a  patient  until  it  is  sufficiently  large  to  be 
accidentally  felt  or  seen.  This  implies  a  growth  of  weeks  or  months,  in 
which  time  it  may  have  developed  the  characteristics  of  assured  benig- 
nancy  or  of  assured  malignancy. 

A  great  number  of  tumors  when  they  first  come  under  observation 
cannot  be  classified  under  either  of  these  headings.  If  gumma  be 
excluded,  the  diagnosis  in  these  doubtful  cases  should  be  formulated 
immediately  by  removal  of  the  tumor  and  the  glandular  tissue  sur- 
rounding it,  and  macroscopic  and  microscopic  examination. 


THE  BREAST 


469 


Among  the  assuredly  benign  growths  may  be  classed  tumors  which 
develop  in  the  breasts  of  girls  and  young  women,  and  which  are  rounded, 
firm,  elastic,  sharply  circumscribed,  movable,  and  unaccompanied  by 
atrophy  of  the  overlying  fat,  skin  adhesion,  or  glandular  enlargement. 
Such  tumors  (intercanalicular  myxoma,  adenofibroma,  solid  or  cystic) 
may  be  single  or  multiple,  but  are  usually  small  and  slow  of  growth. 


Fig.  335 


Ulcerated  cancer  of  breast;  eighteen  months'  duration;  cutaneous  pitting  resembling  orange  skin 
(pig  skin);  retracted  nipple  at  lower  third  of  ulcer.     (Carnett.) 


Of  similar  benignancy  are  the  tumors  which  develop  in  women  who 
have  never  borne  children,  at  or  about  the  menopause,  and  which  are 
multiple,  cystic,  sharply  outlined  from  the  surrounding  tissues,  unaccom- 
panied by  atrophy  of  the  overlying  fat  or  skin  adhesions,  or  more  than 
a  moderate  enlargement  of  the  axillary  glands. 

Finally,  tumors  which  conform  in  type  with  those  just  described,  and 
which  have  existed  for  a  long  time  (years)  without  change  in  size  are 
essentially  benign. 

Tumors  which  are  certainly  malignant  are  characterized  by  the  develop- 
ment of  a  single,  hard,  infiltrating  mass  of  irregular  outline  and  vague 
definition,  associated  with  atrophy  of  the  overlying  fat,  skin  dimpling, 
and  retraction  of  the  nipple.  This  last  symptom,  when  but  slightly 
marked,  must  be  demonstrated  by  comparing  its  freedom  of  motion  when 
drawn  forward  with  that  of  the  nipple  of  the  healthy  breast. 

Skin  dimpling  and  fat  atrophy  are  elicited  by  broadly  encircling  the 


470  THE  THORAX 

breast  tissue  about  the  growth  with  the  two  hands,  Hfting  this  segment 
away  from  the  chest  wall,  and  pressing  the  hands  together.  Multiple, 
indurated,  non-sensitive  axillary  glands,  if  present,  afford  further  cor- 
roboration of  the  malignant  nature  of  the  induration.  All  forms  of 
cancer  in  the  late,  usually  inoperable,  stage  offer  the  clinical  picture  of 
assured  malignancy. 

Whether  the  tumor  be  single  or  multiple,  solid  or  cystic,  rounded  or 
lobulated,  if  it  exhibit  rapid  growth  after  a  quiescent  period,  or  if  it  be 
not  clearly  and  definitely  outlined  from  the  surrounding  breast  tissue, 
the  diagnosis  should  be  formulated  by  operation. 

The  operative  diagnosis  of  benignancy  is  based  mainly  upon  the 
presence  of  distinct  encapsulation ;  in  the  case  of  cysts  upon  the  presence 
of  clear  or  opalescent  fluid,  unless  there  be  an  associated  intracystic 
papilloma,  when  the  cyst  contents  may  be  blood-stained;  and  upon 
the  thin  white  walls  and  distinct  demarcation  from  the  surrounding 
tissues. 

The  operative  diagnosis  of  malignancy  is  based  upon  the  absence  of 
distinct  and  complete  encapsulation,  infiltration  into  the  surrounding 
breast  tissue,  creaking  under  the  knife  and  brittleness  of  tissue,  and  on 
the  presence  of  granular  debris  in  fibrous  spaces. 

In  the  case  of  cysts,  the  bloody  or  grumous  contents,  fungating  intra- 
cystic growths,  thickening  and  irregularity  of  the  cyst  wall,  and  particu- 
larly infiltration  of  the  tissue  surrounding  the  base  of  the  fungating 
intracystic  growth,  are  evidences  of  malignancy.  In  case  of  doubt  after 
careful  consideration  of  the  clinical  history  and  macroscopic  examination 
of  the  excised  growth  a  complete  breast  operation  should  be  performed. 

Mastodynia. — This  is  characterized  by  pain  so  severe  and  recurrent 
or  persistent  as  to  be  crippling.  It  is  most  marked  about  the  menstrual 
period.  It  may  radiate  widely,  and  may  be  associated  with  distinct 
induration,  either  local  or  disseminated,  over  the  whole  breast,  giving  to 
the  examining  fingers  the  sensation  of  a  finely  lobulated  connective-tissue 
mass.  Exceptionally  the  breast  is  entirely  normal  to  palpation,  though 
it  may  exhibit  points  of  tenderness.  The  overlying  skin  is  at  times 
hyperesthetic. 

The  diagnosis  is  often  entirely  symptomatic.  If  careful  palpation 
reveals  one  or  more  small,  superficial,  excessively  tender  nodules,  neuro- 
fibromata  would  be  suggested.  Marked  induration  of  the  whole  breast, 
giving  to  the  examining  fingers  the  sensation  of  a  bag  of  fine  and  large 
shot,  is  indicative  of  chronic  mastitis.  Paroxysms  of  pain  characterized 
by  sudden  swelling,  with  complete  and  rapid  subsidence,  especially  if 
associated  with  other  nervous  phenomena,  are,  for  lack  of  a  better  desig- 
nation, termed  hysterical. 

The  affection  is  persistent,  exhausting,  and  unlikely  to  yield  to  treat- 
ment. In  the  presence  of  demonstrable  lesions,  therapeutic  indications 
are  plain. 

Spontaneous  ecchymosis  of  the  breast  has  been  noted,  often  preceded 
by  severe  pain  and  some  swelling  of  the  breast,  accompanied  by  or 
without  other  symptoms.     It  is  always  associated  with  menstruation. 


THE  ESOPHAGUS  -471 


THE  ESOPHAGUS. 


The  esophagus,  beginning  at  about  the  upper  border  of  the  cricoid 
cartilage,  on  a  level  with  the  sixth  intervertebral  disk,  ends  a  little  short 
of  an  inch  below  the  diaphragm,  opposite  the  body  of  the  eleventh  dorsal 
vertebra. 

Its  beginning  in  the  adult  is  five  and  a  half  to  six  inches  from  the  line 
of  the  teeth,  its  termination  at  the  cardia  is  from  fifteen  to  sixteen  inches 
from  the  same  line,  this  last  measurement  being  less  or  greater  by  two 
inches,  in  proportion  to  stature.  The  distance  from  the  teeth  to  the 
cardia  of  children  from  two  to  twelve  years  old  is  from  nine  to  eleven 
inches. 

There  are  three  points  of  narrowing — the  beginning,  the  position  of 
the  crossing  of  the  left  bronchus,  and  the  site  of  passage  through  the 
diaphragm. 

In  the  adult  the  esophagus  should  admit  from  above  an  instrument 
15  mm.  in  diameter;  from  the  stomach  aspect,  three  fingers  as  far  as  the 
first  joint. 

Its  upper  end  cannot  be  reached  by  a  finger  introduced  through  the 
mouth,  nor  is  it  accessible  to  palpation,  excepting  in  its  cervical  portion, 
where  it  bends  slightly  to  the  left. 

It  is  explored  by  means  of  soft  rubber  tubes,  flexible  woven  bougies 
(cylindrical,  conical,  rat-tailed,  and  elbowed),  bougies  made  with  a 
flexible  handle  twenty  inches  long,  to  which  can  be  attached  metal  bulbs 
of  varying  diameter,  or  the  esophagoscope. 

Instrumental  examination  should  be  preceded  by  thrice  painting  the 
pharynx  and  base  of  the  tongue  at  three  minute  intervals  with  20  per  cent, 
eucaine  lactate  and  0.01  per  cent,  adrenalin  chloride  solution.  In  weak 
patients  death  from  cardiac  inhibition  has  resulted  from  the  attempt 
to  pass  esophageal  instruments. 

Soft,  flexible  instruments  are  passed  with  the  patient  in  a  sitting  posi- 
tion, his  head  leaning  slightly  forward.  The  surgeon's  left  index  finger 
is  passed  to  the  base  of  the  tongue  and  guides  the  tip  of  the  instrument 
backward  against  the  posterior  wall  of  the  pharynx  while  it  also  holds 
the  tongue  forward.  Muscular  spasm,  violent  cough,  dyspnea,  and 
vomiting  efforts  usually  make  the  first  essay  difficult.  Once  having 
entered  the  esophagus,  the  head  of  the  patient  may  be  extended.  The 
further  passage  of  the  instrument  into  the  stomach  is,  in  the  normal 
esophagus,  unobstructed. 

Direct  inspection  is  practicable  through  the  esophagoscope,  a  long 
straight  tube  of  from  10  to  15  mm.  diameter  and  varying  in  length  in 
accordance  with  the  needs  of  the  case,  provided  with  a  cold  lamp  in  its 
extremity  and  a  conical  obturator.  Its  introduction  is  possible  only  with 
the  head  in  a  position  of  extreme  extension.  It  forces  the  cricoid  carti- 
lage forward  and  produces  bruising  of  the  upper  extremity  of  the  esopha- 
gus. It  gives  a  view  of  the  esophageal  walls  throughout  their  entire 
extent. 


472  THE  THORAX 

Auscultation  of  the  esophagus  to  the  left  of  the  spine  of  the  eleventh 
dorsal  vertebra  is  useful  at  times.  Fluid  is  by  a  swallowing  motion 
squirted  into  the  lower  part  of  the  esophagus,  where  it  remains  six  seconds. 
The  cardiac  orifice  of  the  stomach  then  opens  and  the  fluid  enters  this 
viscus  with  a  gurgling  sound.  Delay  of  this  sound  or  its  absence  would 
suggest  narrowing  or  spasm  at  or  near  the  cardia. 

The  cardinal  symptoms  of  esophageal  disease  are  difficulty  in  swallow- 
ing, pain  usually  aggravated  by  this  act,  regurgitation  of  food  which 
does  not  contain  gastric  juice,  and  often  reflex  cough. 

These  symptoms  are  also  characteristic  of  inflammations  of  the  pharynx 
and  tonsils,  postpharyngeal  abscess,  and  palsy  of  the  palate  or  of  the 
pharyngeal  constrictors. 

The  throat  lesions  which  cause  these  symptoms  are  amenable  to  direct 
inspection  and  palpation,  in  cases  of  inflammation  and  abscess,  and  the 
pain  is  referred  to  the  throat. 

The  regurgitation  incident  to  palsy  secondary  to  infectious  disease, 
particularly  diphtheria,  is  immediate  and  usually  partly  nasal. 

Congenital  Malformations  of  the  Esophagus. — This  portion  of  the  ali- 
mentary canal  may  be  transposed,  duplicated,  dilated,  or  strictured.  It 
may  be  imperforate  or  may  exhibit  fistulse. 

Congenital  stricture,  characterized  by  lifelong  difficulty  of  deglutition, 
is  often  associated  with  diverticula. 

Esophagotracheal  fistula  causes  a  spasmodic  coughing  up  of  the 
ingested  fluid  when  the  infant  is  nourished. 

Imperforate  esophagus  may  take  the  form  of  diaphragmatic  closure 
or  complete  absence. 

Rupture  of  the  Esophagus. — Rupture  of  the  esophagus  occurring  during 
violent  vomiting  has  been  noted  in  the  lower  end  of  this  tube,  probably 
predisposed  to  by  abnormal  condition;  characterized  by  violent  pain, 
shock,  inability  either  to  swallow  or  vomit,  emphysema  at  the  base  of 
the  neck,  and  death  within  twenty-four  hours. 

Diagnosis  might  be  suggested  by  the  dysphagia  and  the  prominence 
of  the  thoracic  symptoms. 

Acute  Esophagitis. — Acute  esophagitis,  usually  due  to  the  ingestion  of 
a  corrosive  liquid,  is  usually  masked  in  its  symptomatology  by  the  asso- 
ciated lesions  of  the  mouth  and  stomach  which  establish  the  diagnosis. 
The  tissue  necrosis  is  greatest  at  the  three  points  of  normal  narrowing. 

The  esophagus  may  be  traumatized  from  within  by  instrumentation 
or  by  the  swallowing  of  small  sharp  or  pointed  foreign  bodies  which 
may  or  may  not  be  arrested  in  its  substance.  Instrumentation  may  cause 
perforation  and  abscess,  but  not  in  a  healthy  esophagus.  It  often  occa- 
sions an  acute  catarrhal  esophagitis  limited  to  the  upper  orifice. 

The  acute  inflammation  incident  to  the  lodgement  of  a  small  sharp 
foreign  body  is  characterized  by  sudden  sticking  pain  fairly  well  localized 
behind  the  sternum,  aggravated  greatly  by  swallowing  solids,  growing 
worse  shortly  (hours  or  days),  followed  by  dysphagia,  the  constitutional 
symptoms  of  infection,  and  often  the  eructation  of  blood  and  pus. 

This  condition  is  distinguished  from  the  burning  pain  incident  to  an 


THE  ESOPHAGUS  473 

esophageal  scratch,  from  the  circumstance  that  the  latter  within  twenty- 
four  hours  begins  to  grow  better,  and  the  slight  dysphagia  is  one  of  pain 
rather  than  of  mechanical  obstruction  and  muscular  infiltration. 

Acute  inflammation  secondary  to  periesophageal  phlegmon  of  verte- 
bral, glandular,  or  tracheal  origin  would  probably  be  suggested  by  the 
symptoms  of  the  primary  disease  and  the  absence  of  other  adequate 
cause.  There  is  burning  pain  aggravated  by  swallowing,  or  at  times 
even  by  moving  the  neck,  and  usually  the  constitutional  signs  of 
profound  toxemia. 

Foreign  Bodies. — Foreign  bodies,  particularly  frequent  in  children,  are 
arrested  at  either  extremity  of  the  esophagus  or  the  position  of  the  bron- 
chial crossing.  The  characteristic  symptoms  are  great  and  suffocating 
pain,  fruitless  vomiting  efforts,  strangling  cough,  and  dysphagia.  Fatal 
dyspnea  may  result  from  the  high  lodgement  of  a  large  body.  In  hours 
or  days  (exceptionally  weeks)  the  constitutional  and  local  symptoms  of 
infection  develop.  Periesophageal  suppuration  may  lead  to  mediastinal 
infection  and  inflammation  of  the  pleura  and  pericardium,  or  perforation 
into  the  air  passages  or  the  great  bloodvessels. 

Though  the  immediate  symptoms,  because  of  the  associated  laryngeal 
spasm,  are,  exceptionally,  much  like  those  of  foreign  body  in  the  air  pas- 
sages, the  dyspnea  and  cough  are  usually  moderate  and  the  patient  by 
his  own  sensations  makes  the  correct  diagnosis.  This  should  be  made 
absolutely  and  immediately  by  the  x-ray  when  this  is  applicable  (teeth, 
coins,  etc.),  the  esophageal  bougie,  and,  in  the  case  of  small  sharp  bodies 
(fish-bones),  by  the  esophagoscope. 

Esophagismus. — Esophagismus,  manifested  by  involuntary  contrac- 
tion of  the  upper  opening  of  the  canal,  is  a  neurosis  usually  occurring 
in  young  women  exhibiting  other  signs  of  hysteria.  It  is  an  occasional 
reflex  of  an  erupting  wisdom  tooth.  The  attack  which  comes  on  sud- 
denly is  characterized  by  dysphagia,  eructation  of  the  pharyngeal  con- 
tents, pain,  often  severe,  a  sense  of  constriction,  and  dyspnea.  These 
symptoms  may  recur  at  each  effort  at  deglutition  for  days  or  months. 
More  commonly  they  are  distinctly  intermittent,  and  the  difficulty  in 
swallowing  corresponds  to  no  mechanical  law,  since  warm  food  can 
sometimes  be  taken  with  ease  while  cold  food  brings  on  the  spasm,  or 
one  liquid  may  be  taken  with  impunity  while  another  equally  bland  is 
promptly  rejected. 

The  diagnosis  is  suggested  by  the  immediate  rejection  of  food  before 
it  leaves  the  pharynx,  the  high  seat  of  pain,  the  variability  of  the  symp- 
toms, and  is  confirmed  by  an  examination  with  a  bulbous  bougie  under 
an  anesthetic. 

Cardiospasm. — Cardiospasm  may  be  acute  in  onset,  especially  when 
it  follows  traumatism  to  the  chest  wall.  It  may  be  reflex  or  incident 
to  degenerative  changes  in  the  vagus.  This  nerve  sends  fibers  to  the 
intrinsic  ganglia  of  the  cardia  which  keep  this  muscle  in  a  condition  of 
tonic  contraction;  this  contraction  will  be  permanent  if  the  inhibitory 
fibers  are  destroyed. 

Cardiospasm  is  characterized  in  its  beginning  by  much  the  same 


474  THE  THORAX 

symptoms  as  esophagismus,  except  that  the  burning  pain  and  point  of 
stoppage  are  located  behind  the  midportion  of  the  sternum.  In  the 
early  stages  food  is  regurgitated  at  once. 

The  symptoms  may  be  evanescent,  recurring,  or  persistent. 

The  bougie  is  resisted  strongly  just  as  it  is  about  to  pass  into  the 
stomach  (sixteen  inches  from  the  line  of  the  teeth),  but  on  sustained 
gentle  pressure  passes  in  quite  suddenly.  Moreover,  a  large  instrument 
will  at  times  pass  more  readily  than  a  small  one. 

Cardiospasm  with  Diffuse  Dilatation  of  the  Esophagus. — This  is  char- 
acterized by  precisely  the  symptoms  of  deep  diverticulum.  There 
is  increasing  dysphagia,  pain  behind  the  sternum  after  eating,  dry 
cough,  and  eructation  of  putrid  food.  On  lying  down,  there  is  an  almost 
effortless  regurgitation  of  food  unmixed  with  gastric  contents.  This 
regurgitation  occurs  at  other  times  often  assisted  by  voluntary  muscular 
actions  having  for  their  end  increased  intrathoracic  pressure.  There 
is  no  vomiting  or  belching  of  gas. 

These  patients  select  their  diet  most  carefully,  and  often  go  through 
extraordinary  movements  to  force  the  food  into  the  stomach.  With 
the  fusiform  dilatation  of  the  esophagus  there  is  usually  an  associated 
muscular  hypertrophy  of  its  walls. 

The  diagnosis  is  based  upon  the  deep  position  of  the  obstruction, 
42  cm.  from  the  line  of  the  teeth,  its  yielding  to  steady  gentle  pressure, 
its  irregularity,  since  at  one  time  an  instrument  passes  readily,  while  at 
another  its  introduction  is  impossible.  Examination  with  the  esophago- 
scope  shows  a  lax,  catarrhal,  dilated  esophagus,  obstructed  at  the  cardia 
by  muscular  spasm. 

The  prognosis  of  the  affection  in  its  progressive  form  (increasing 
dilatation)  is  bad.  It  may  last  through  a  long  life  unrecognized  if 
the  dilatation  is  adequately  combated  by  hypertrophy. 

The  round  peptic  ulcer  attacks  the  esophagus  directly  or  in  the  form 
of  an  extension  from  the  stomach.  It  may  bleed  freely,  thus  simulating 
gastric  ulcer. 

Both  tuberculous  and  syphilitic  lesions  have  been  observed,  but  give 
no  characteristic  symptoms  other  than  those  incident  to  subsequent 
cicatricial  contraction.  Papillomata  and  retention  cysts  have  been 
seen  through  the  esophagoscope. 

Varices  of  the  lower  part  of  the  esophagus  (in  atrophic  cirrhosis  of 
the  liver)  may  cause  profuse  bleeding  indistinguishable  from  that  coming 
from  the  stomach. 

Stricture  of  the  Esophagus. — Stricture  of  the  esophagus  may  develop 
within  ten  days  following  a  chemical  destruction  of  tissue.  Usually 
it  occurs  within  six  months.  When  caused  by  the  ingestion  of  cauter- 
izing agents,  it  is  placed  by  preference  at  the  points  of  physiological 
narrowing.  There  is  usually  a  proximal  hypertrophy  of  muscles,  pre- 
venting dilatation,  and  always  a  chronic  catarrhal  condition  of  the 
mucous  membrane,  which  in  itself  increases  the  narrowing.  The 
stricture  due  to  either  the  peptic  ulcer,  at  the  lower  end  of  the  tube, 


THE  ESOPHAGUS  475 

or  the  gumma,  is  not  preceded  by  symptoms  sufficiently  characteristic 
for  the  formation  of  a  diagnosis  of  the  exciting  cause. 

The  characteristic  symptom  of  stricture  is  dysphagia  which  may 
develop  quite  suddenly.  As  a  rule,  it  comes  on  gradually,  first  being 
exhibited  toward  solids,  later  toward  soft  food  and  liquids.  Patients 
thus  afflicted  learn  to  select  their  diet  with  great  care,  make  violent 
efforts  at  swallowing,  and  regurgitate  masticated  food  without  admix- 
ture of  the  stomach  contents.  There  is  severe  poststernal  pain,  relieved 
by  regurgitation,  ^^'hen  untreated,  the  tendency  to  complete  obstruc- 
tion is  pronounced. 

Diagnosis  is  suggested  by  the  history  of  a  preceding  esophagitis 
and  is  assured  by  examination  with  bougies.  The  bougie  will  exclude 
paralytic  dysphagia  and  esophagismus,  and  usually  cardiospasm  and 
diverticuliun. 

Stricture  due  to  malignant  infiltration  is  an  affection  of  the  middle 
aged,  being  commonest  in  men  past  fifty.  It  is  exceptional  before  the 
fortieth  year.  The  seats  of  preference  are  those  of  stricture,  the  greater 
number,  perhaps,  being  found  at  the  bronchial  crossing.  Chronic 
esophagitis  is  a  predisposing  factor. 

The  diagnosis  is  suggested  by  pain,  worse  at  night  and  poststernal 
or  referred  to  the  back,  toxic  anemia  and  dysphagia,  not  necessarily 
very  pronounced,  occurring  in  a  man  past  middle  age.  Nodular  enlarge- 
ment of  one  or  more  supraclavicular  glands  would  be  corroborative. 

The  passage  of  bougies  and  the  esophagoscope  often  makes  the  diag- 
nosis absolute. 

In  its  early  stages  the  condition  is  almost  never  recognized.  In  its 
later  stages  regurgitation  of  masticated  food  containing  blood  and 
mucus,  harassing  and  spasmodic  cough,  alteration  in  the  voice, 
contraction  of  one  pupil  (sympathetic),  and  supraclavicular  glandular 
enlargement  in  conjunction  with  esophagoscopy  suggest  diagnosis.  This 
disease  may  run  its  entire  course  without  dysphagia  or  eructation. 

Obstruction  due  to  pressure  from  without,  as  from  goitre,  h}'per- 
plastic  mediastinal  gland,  aneurysm,  or  malignant  tumor,  is  usually 
recognized  as  such,  since  because  of  the  movability  of  the  esophagus  it 
is  not  compressed  untill  these  tumors  reach  such  size  as  to  be  recognized 
by  the  physical  signs.  Malignant  mediastinal  infiltration  may  by  exten- 
sion involve  the  esophagus  early  and  cause  dysphagia  before  the  original 
tumor  is  sufficiently  developed  to  formulate  a  diagnosis. 

Polypi. — Polypi  (adenofibromata)  are  rare.  They  usually  grow  from 
the  upper  extremity  of  the  esophagus  or  from  the  pharynx,  and  occasion 
no  symptom  except  dysphagia  and,  when  the  pedicle  is  long,  attacks  of 
dyspnea. 

Diagnosis  should  be  made  by  examination  with  bougies,  the  laryngo- 
scope, and  the  esophagoscope. 

Diverticula  of  the  Esophagus. — Diverticula  of  the  esophagus  commonly 
arise  from  the  posterior  wall  of  the  pharyngo-esophageal  junction  at 
a  point  of  normal  weakness  (constrictor  fibers  absent).  The  diver- 
ticulum is  slow   (many  years)   in  development,   ultimately  forming  a 


476  THE  THORAX 

pouch  projecting  downward  along  the  canal,  and,  when  filled  with  food, 
compressing  the  latter. 

In  its  early  stages,  and  at  times  through  life,  it  is  characterized  by  no 
other  symptom  than  eructation  of  food,  and  can  be  distinguished  from 
stomach  rumination  by  examination  of  this  food  for  gastric  juice. 

When  of  sufficient  development  to  mechanically  interfere  with  swal- 
lowing, it  is  manifested  by  dysphagia,  pain  relieved  by  eructation  of 
stinking  food  without  gastric  juice,  tumor  of  the  neck  in  case  of  a  high 
diverticulum  (not  always),  which  can  be  emptied  into  the  pharynx  by 
external  pressure.  A  bougie  usually  passes  directly  into  the  diverticulum 
and  is  arrested  by  its  fundus.  A  second  bougie  passed  beside  the  first 
readily  slips  into  the  stomach. 

Diverticula  of  the  lower  part  of  the  esophagus,  usually  rising  from 
the  anterior  surface  near  the  brachial  bifurcation,  may  be  difficult  to 
distinguish  from  dilatation  secondary  to  cardiospasm.  In  each  there 
may  be  slow  onset,  steady  progression,  dysphagia,  pain,  and  eructation 
of  large  quantities  of  putrid  but  non-digested  food  with  relief  of 
pain.  The  opening  into  the  diverticulum  may  be  found  or  avoided 
at  will  by  the  use  of  an  elbowed  bougie  or  woven  stomach  tube.  If 
two  be  passed  in  succession,  after  lodgement  of  one  the  other  may  pass 
by  it  and  readily  enter  the  stomach.  On  injection  through  these  two 
bougies  of  a  colored  and  a  clear  solution,  one  into  the  diverticulum, 
the  other  into  the  stomach,  there  will  be  no  mixing  of  these  two  unless 
more  has  been  poured  into  the  diverticulum  than  it  is  capable  of  hold- 
ing. The  ingestion  of  bismuth  and  mashed  potatoes  may  enable  a 
characteristic  a;-ray  picture  to  be  taken. 

The  use  of  the  esophagoscope  may  be  needful  before  diagnosis  is 
made.  Indeed,  this  may  remain  doubtful  even  after  careful  examination 
with  that  instrument. 


CHAPTER    XVI. 

THE  ABDOMEN. 

Contusion. — Contusion  is  followed  by  pain,  shock,  and  vomiting. 
Exceptionally  shock  may  be  almost  immediately  fatal  in  the  absence 
of  demonstrable  lesions. 

As  a  rule,  the  shock  and  pain  are  proportionate  in  their  severity  and 
persistence  to  the  intra-abdominal  lesion.  Neither  vomiting  of  blood 
nor  its  appearance  in  the  stool  is  in  itself  diagnostic  of  gastric  or  intes- 
tinal rupture. 

The  symptoms  on  which  the  diagnosis  of  rupture  is  based  are  severe 
and  persistent  pain,  shock  from  which  reaction  takes  place  in  the  course 
of  hours  rather  than  minutes,  tenderness  to  deep  pressure,  increasing 
rather  than  diminishing  muscular  rigidity,  and  the  rapid  development 
of  symptoms  of  diffuse  peritonitis. 

In  distinguishing  between  hemorrhage  and  perforation,  the  greater 
pain  of  the  latter,  the  more  rapid  development  of  peritonitis,  and 
increased  vascular  tension  with  the  onset  of  inflammation  would  be 
significant. 

A  rapidly  developing  movable  flank  dulness  may  be  elicited  in  severe 
hemorrhage,  and  often  rectal  tenesmus  from  accumulation  of  blood  in 
the  rectovesical  peritoneal  pouch. 

In  certain  exceptional  cases,  after  the  first  transitory  pain  and  perhaps 
vomiting,  neither  shock  nor  other  signs  of  intraperitoneal  trouble  develop 
for  many  hours.  These  cases  are  characterized  after  the  immune  interval 
by  the  sudden  outbreak  of  symptoms  of  acute  perforative  peritonitis. 
The  stomachs  of  habitual  drunkards  may  be  ruptured  by  slight  violence 
or  even  in  the  absence  of  this.  Intestinal  rupture  from  contusion  is 
commonest  in  the  upper  part  of  the  jejunum. 


PERITONITIS. 

Peritonitis,  intestinal  obstruction,  and  gastro-enteritis  so  commonly 
complicate  surgical  affections  of  the  abdominal  viscera  that  a  knowl- 
edge of  their  diagnostic  features,  aside  from  the  agents  which  cause 
them,  is  important. 

The  peritoneum,  a  serous  membrane  about  equal  in  area  to  that  of 
the  skin,  exhibits  an  extraordinary  power  of  both  absorption  and  exuda- 
tion; the  former  is  best  developed  in  its  diaphragmatic  portion.  The 
latter  is  expressed  as  a  serous,  fibrinous,  or  purulent  effusion,  or  com- 
binations of  these  in  accordance  with  the  nature  and  progressive  viru- 
lence of  the  exudative  agent. 


478  THE  ABDOMEN 

Peritonitis,  almost  never  primary,  with  perhaps  the  exception  of  the 
pnemnonic  form  observed  mainly  in  children,  is  due  to  the  extension  of 
infection  from  the  organs  which  this  membrane  covers. 

It  may  be  acute  or  chronic,  local  or  diffused. 

Acute  Local  Peritonitis. — Acute  local  peritonitis,  usually  incident  to 
extension  of  inflammation  from  the  appendix,  gall-bladder,  or.  Fallopian 
tubes,  is  characterized  by  persistent  burning,  stabbing,  colicky  pain, 
rapid  in  onset,  at  first  referred  to  the  umbilical  region,  later  to  the  seat 
of  inflammation,  often  with  peripheral  radiations  or  references. 

Tenderness  at  or  about  the  seat  of  maximum  inflammation  is  elicited 
by  deep  pressure,  palpation,  or  by  coughing  or  forceful  breathing. 

There  is  local  tympany  and  lessened  or  absent  peristalsis  in  the  por- 
tion of  the  gut  involved,  hence  constipation  and  vomiting. 

The  overlying  muscles  are  persistently  rigid.  There  is  usually  general 
tympany  and  tenderness,  nausea,  vomiting,  and  constipation. 

Fever  and  leukocytosis  are  usual.     The  pulse  is  hard  and  hurried. 

Acute  Diffuse  Peritonitis. — ^Acute  diffuse  peritonitis,  when  due  to  a 
suddenly  developing  cause,  usually  the  rupture  of  an  ulcerated  or 
inflamed  hollow  viscus  or  of  an  abscess  lying  within  the  peritoneal 
cavity  or  in  a  part  covered  by  it,  is  characterized  by  sudden  violent  pain 
of  overwhelming  intensity,  attended  with  shock,  vomiting,  and  general 
abdominal  tenderness,  shordy  followed  by  wooden  rigidity  of  all  the 
abdominal  muscles,  absence  of  peristalsis,  tympany,  absolute  constipa- 
tion, shallow  thoracic  respiration,  and  persistent  vomiting.  The  fre- 
quently repeated  vomiting  becomes  regurgitant  in  t}^e,  the  patient 
spitting  out  brownish  offensive  fluid  every  few  minutes. 

With  the  constitutional  and  local  reaction  against  irritation  and  infec- 
tion, fever  and  leukocytosis  develop.  With  fever  there  is  a  hurried, 
wiry  pulse  which,  with  the  advent  of  tympany  and  overwhelming  intoxi- 
cation, becomes  rapid,  intermittent,  and  almost  or  quite  imperceptible 
at  the  wrist. 

Dorsal  decubitus,  with  slightly  flexed  thighs  and  raised  head  and 
shoulders,  is  suggestive  of  the  judgment  of  the  nurse  rather  than  the 
nature  of  the  disease.  Death  from  vasomotor  paresis  may  occur  without 
inflammatory  reaction,  the  symptoms,  aside,  from  the  agonizing  pain, 
being  those  of  profound  shock.  It  is  usually  toxic,  incident  to  septic 
absorption  mainly  from  the  bowel  contents,  peritonitis  always  occasion- 
ing paralysis  of  the  intestinal  muscles. 

On  no  single  symptom  can  the  diagnosis  of  acute  peritonitis  be  form- 
ulated. The  pathognomonic  symptom  group  is  severe  pain,  tender- 
ness, muscular  rigidity,  thoracic  breathing,  tympany,  feeble  or  absent 
peristalsis,  vomiting,  and  fever  with  hurried,  wiry  pulse  and  constipation. 
Very  exceptionally,  and  usually  signiflcant  of  profound  sepsis,  the  belly 
is  flat  and  there  is  diarrhea. 

In  diffuse  peritonitis  the  appearance  is  always  that  of  serious  illness. 
The  diagnosis  of  the  terminal  stage  is  of  little  service. 

Acute  intestinal  obstruction,  especially  when  due  to  strangulation, 
is  distinguished  from  peritonitis,  in  its  early  stages,  by  the  absence  of 


PERITONITIS  479 

fixation  rigidity  and  the  presence  of  exaggerated  peristalsis.  Later 
the  conditions  are  combined. 

Pulmonary  affections  and  pericarditis  may  cause  severe  pain  referred 
to  the  abdomen,  with  tympany,  vomiting,  and  constipation,  but  tender- 
ness is  not  best  elicited  on  deep  palpation,  nor  is  there  absent  peristalsis 
nor  pronounced  or  persistent  rigidity;  except  in  diaphragmatic  pleurisy 
the  abdominal  respiratory  movement  is  unaffected,  while  the  hurried 
respirations  in  the  one  case  and  signs  of  local  lesion  in  the  other  should 
at  least  suggest  a  diagnosis. 

The  abdominal  pain  of  certain  infections,  such  as  typhoid,  influenza, 
acute  rheumatic  fever,  the  exanthemata,  or  of  angioneurotic  edema, 
uremia,  gout,  ataxia,  plumbism,  or  gastralgia,  is  accompanied  by  a 
history  or  other  symptoms  characteristic  of  each  affection,  nor  is  the 
convincing  symptom-complex  of  peritonitis  ever  seen. 

Angioneurotic  edema,  often  hereditary,  usually  beginning  in  child- 
hood, and  characterized  in  its  early  development  by  the  sudden  appear- 
ance of  edematous  surface  patches,  may  be  characterized  by  visceral 
crises,  strongly  suggesting  either  obstruction  or  peritonitis.  There  is 
pain,  which  may  be  shocking  in  intensity,  vomiting  which  often  contains 
blood,  and  later  diarrhea. 

The  abdomen  is  usually  retracted.  There  is  no  irue  muscular  rigidity, 
nor  is  there  characteristic  tenderness  to  deep  pressure.  Exceptionally 
these  symptoms  may  be  associated  with  tympany  and  intestinal  paresis, 
in  which  case  the  history  should  be  carefully  considered  in  making  a 
diagnosis,  and  search  of  the  surface  should  be  made  for  purpuric  spots. 
Similar  crises  are  noticed  as  prodromal  of  the  erythematous  skin  diseases. 

Inflammation  of  the  abdominal  wall  is  characterized  by  the  local 
and  usually  readily  demonstrable  symptoms  of  this  affection,  by  the 
fact  that  tenderness  is  located  in  the  wall  and  not  beneath  it,  and 
by  the  absence  of  the  symptoms  of  peritoneal  involvement.  If  sub- 
aponeurotic inflammation  be  complicated  by  local  peritonitis,  the 
recognition  of  the  combined  lesions  may  be  difficult. 

Rheumatic  neuralgia  of  the  abdominal  muscles  produces  both  tender- 
ness and  rigidity,  which  usually  involves  the  whole  of  at  least  one  side, 
is  distinctly  superficial,  and  is  aggravated  by  movement.  In  this  affec- 
tion, as  also  in  neuritis,  cutaneous  hyperesthesia  is  well  marked,  and 
in  neuritis  points  of  nerve  tenderness  can  be  demonstrated.  Peristalsis 
is  unaffected,  there  is  no  meteorism;  unless  the  diaphragm  be  directly 
involved,  it  moves  freely  and  muscular  tenderness  is  relieved  by  warm, 
broad  pressure. 

Perirenal  inflammation  exhibits  tenderness,  best  elicited  by  pressure 
in  the  costovertebral  angle.  The  pain  is  in  the  renal  region  and  is 
referred  along  the  lower  intercosto-abdominal  nerves  to  the  abdomen. 
It  customarily  radiates  along  the  course  of  the  ureter  to  the  bladder. 
Though  one  side  of  the  abdomen  may  be  rigid,  muscular  fixation  is 
most  marked  over  the  renal  region. 

Spinal  caries,  aneurysm  of  the  abdominal  aorta,  spondylitis  deformans, 
and  acute  osteomyelitis  of  the  spine  may  occasion  pain  and  rigidity 


480  THE  ABDOMEN 

which  in  themselves  may  simulate  peritonitis  but  are  unaccompanied 
by  other  gastro-intestinal  symptoms. 

Arteriosclerosis  is  exceptionally  characterized  by  crises  of  pain  which 
may  be  attended  by  vomiting  and  tympany.  Inflammatory  symptoms 
are  absent  and  nitrites  may  give  relief. 

Hysterical  pseudoperitonitis  may  present  many  of  the  signs  of  grave 
inflammation,  including  in  rare  instances  fecal  vomiting,  which,  how- 
ever, is  likely  to  be  attended  by  a  violent  retching.  Neither  fever  nor 
leukocytosis  is  present;  nor  is  the  facies  that  of  profound  illness. 
The  onset  is  unattended  by  the  shock  and  vasomotor  paresis  of  true 
fulminant  peritonitis,  and  the  symptoms  will  be  found  lacking  in  proper 
relationship  to  each  other  and  often  markedly  influenced  by  suggestion. 

The  non-infectious  forms  of  acute  diffuse  peritonitis,  such  as  are 
incident  to  hemorrhage,  as  from  a  ruptured  extra-uterine  pregnancy, 
or  extravasation  of  sterile  urine,  exhibit  typical  symptoms.  The  diag- 
nosis as  to  cause  must  be  based  on  the  history  and  on  findings  other 
than  those  incident  to  the  inflamed  peritoneum,  though  the  form  of 
the  affection  is  less  fulminant  in  development  and  pursues  a  slower 
course  than  that  characteristic  of  the  septic  type.  The  differential 
diagnosis  should  be  made  by  celiotomy. 

Chronic  Peritonitis .^ChrOnic  peritonitis,  which  may  be  local  or  diffuse, 
may  be  almost  symptomless  except  for  a  serous  exudate,  or  may  be 
characterized  by  irregularly  recurring  subacute  or  acute  attacks,  con- 
valescence from  such  attacks  never  being  complete.  Even  during 
acute  exacerbations  pain,  tenderness,  and  rigidity  are  never  as  pronounced 
as  in  acute  pyogenic  inflammation,  and  fever  and  leukocytosis  are  slight 
or  wanting.  Constipation  often  alternates  with  diarrhea  and  partial 
obstruction  with  muscular  hypertrophy  of  the  intestinal  wall,  and  exag- 
gerated peristalsis  is  common. 

Chronic  peritonitis  may  be  due  to  tuberculosis  (common),  carcinoma 
(less  common),  actinomycosis  (rare),  or  serositis  (rare),  and  may  exhibit 
either  a  serous  or  fibrinoplastic  exudate. 

Tuberculous  Peritonitis. — Tuberculous  peritonitis,  especially  an  affec- 
tion of  children,  is  characterized  chiefly  by  cachexia  and  fluid  distention 
of  the  abdomen,  which  in  the  serous  type  may  be  painless.  In  the 
fibrinous  type,  recurring  colicky  pains  with  tenderness  are  common, 
and  irregular  nodular  masses  may  be  felt  due  to  tuberculoma  of  the 
omentum  or  the  mesenteric  glands.  In  the  absence  of  mixed  infection 
fever  and  leukocytosis  are  but  slightly  marked. 

Chronic  fibrinous  peritonitis,  often  most  pronounced  about  the  tubes 
or  appendix,  sometimes  confined  to  these  regions,  is,  if  tuberculous,  sec- 
ondary to  involvement  of  these  structures.  The  symptoms  may  be 
those  of  mechanical  obstruction  caused  by  contracture  and  adhesions 
rather  than  those  of  inflammation. 

Associated  tuberculous  lesions  elsewhere,  a  positive  tuberculin  test,  the 
injection  of  a  susceptible  animal  with  aspirated  fluid,  direct  inspection 
through  an  incision,  and  microscopic  examination  are  the  diagnostic 
means. 


INTESTINAL  OBSTRUCTION  481 

Diffuse  carcinoma  of  the  peritoneum,  usually  secondary,  is  char- 
acterized by  a  serosanguineous  exudate,  and  in  the  terminal  stages  by 
distinct  nodulations. 

Diagnosis  is  suggested  by  the  history  of  a  primary  lesion,  rapidity 
of  progress,  the  profound  and  progressive  deterioration  in  general 
health,  and  by  exploratory  operation. 

Multiple  serositis  is  characterized  by  chronic  inflammation  of  the 
pericardium,  pleura,  and  peritoneum,  with  serous  exudate  into  the  cavity 
of  each  of  these  structures. 


INTESTINAL  OBSTRUCTION. 

Intestinal  obstruction  may  be  due  to  a  paralytic  condition  of  the 
bowel  muscle,  in  which  case  it  is  termed  dynamic,  or  to  occlusion  of 
its  lumen,  in  which  case  it  is  termed  mechanical.  As  opposed  to  peri- 
tonitis, intestinal  obstruction,  except  in  its  dynamic  form,  is  char- 
acterized by  exaggerated  peristalsis,  straining  and  propulsive  vomiting, 
and  absence  of  fixation  rigidity  of  the  abdominal  wall.  The  two  con- 
ditions are  often  combined,  since  dynamic  ileus  is  an  almost  invariable 
accompaniment  of  acute  diffuse  peritonitis,  and  peritonitis  is  equally 
certain  to  follow  unrelieved  acute  obstruction. 

Dynamic  Ileus. — Dynamic  ileus  is  most  typically  exemplified  as  it 
occurs  in  acute  diffuse  peritonitis.  It  may  follow  operation,  in  the 
absence  of  inflammation,  as  a  consequence  of  rough  or  prolonged 
manipulations  or  of  peritoneal  chill.  Exceptionally  it  develops  after 
abdominal  contusion,  or  is  caused  by  excessive  gaseous  distention 
or  splanchnic  or  spinal  nerve  degeneration.  It  is  a  common  terminal 
condition,  often  directly  causative  of  death  in  systemic  diseases  such 
as  pneumonia,  nephritis,  meningitis,  and  typhoid  fever. 

In  its  mild  and  transitory  form  it  follows  all  abdominal  operations, 
probably  incident  to  a  traumatic  non-infective  peritonitis,  accompanies' 
renal,  biliary,  ovarian,  or  pancreatic  colic,  indeed,  any  acute  intraperi- 
toneal or  juxtaperitoneal  congestion  or  inflammation  sufficiently  pro- 
nounced to  cause  severe  pain.  It  is  then  characterized  by  tympany, 
constipation,  and  absent  or  feeble  peristalsis.  The  vomiting,  if  present, 
is  of  reflex  pain  origin  and  is  not  persistently  recurring,  nor  do  the 
symptoms  of  toxic  absorption  develop. 

Characteristic  symptoms  of  acute  dynamic  ileus  are:  absent  peristalsis; 
progressive,  uniformly  distributed  abdominal  tympany,  marked  by  a 
tense,  rounded  belly  wall,  in  which  individual  intestinal  coils  cannot 
be  felt;  shallow,  hurried  respiration,  because  of  upward  pressure;  rapid, 
weak,  irregular  heart  action,  caused  at  first  by  pressure,  later  by  toxemia; 
profuse,  persistently  recurring,  regurgitant  vomiting  of  an  offensive 
thin  fluid,  made  brown  or  black  by  the  presence  of  minute  coagula; 
absolute  constipation  to  both  feces  and  flatus;  and  pain  which,  aside 
from  that  of  the  causative  factor,  is  not  severe,  is  not  colicky  in  char-: 
acter,  and  is  much  bettered  by  the  evacuation  of  gas. 
31 


482  THE  ABDOMEN 

The  constitutional  symptoms  are  those  of  toxic  absorption.  The 
urine  is  scanty,  concentrated,  and  contains  an  excess  of  indican.  When 
the  condition,  as  is  usually  the  case,  is  caused  by  peritonitis,  the  pro- 
nounced pain,  tenderness,  rigidity,  and  often  fever  and  leukocytosis  of 
this  condition  are  present. 

Incident  to  the  enormous  distention  which  follows  hard  upon  paralysis 
of  the  bowel  muscle  and  the  consequent  angulation  of  the  gut,  the 
dynamic  ileus  quickly  becomes  mechanical. 

Mesenteric  thrombosis  and  embolism  depart  from  the  type  of  strangu- 
lation ileus  in  the  fact  that,  though  they  may  begin  with  agonizing  or  shock- 
ing pain,  vomiting,  tenderness,  and  local  meteorism,  one  or  more  profuse 
blood-stained  passages  are  common  and  free  fluid  is  early  developed  in 
the  peritoneal  cavity;  occasionally  a  palpable  blood  tumor  can  be  felt 
between  the  layers  of  the  mesentery.  In  the  embolic  form  of  the  affection 
there  is  usually  valvular  disease  of  the  heart,  and  emboli  may  develop  in 
other  parts  of  the  body,  or  they  may  have  previously  manifested  them- 
selves. 

Mechanical  Ileus  without  Strangulation. — This  differs  in  symptoma- 
tology from  that  accompanied  by  strangulation  in  its  less  sudden,  painful, 
and  shocking  onset  and  the  much  slower  development  of  symptoms 
of  profound  intestinal  toxemia  and  ultimate  diffuse  peritonitis.  The 
absolute  constipation,  the  recurring  explosive  vomit,  the  exaggerated 
peristalsis,  and  the  progressive  tympany  are  characteristic. 

Fecal  vomiting  in  any  form  of  intestinal  obstruction  is  a  terminal 
symptom,  hence  of  little  use  in  framing  a  serviceable  diagnosis. 

Obturation  Ileus. — Obstructive  ileus,  or  mechanical  obstruction  of  the 
gut  by  a  plug  or  mass  within  its  lumen,  is  in  its  mild  form  usually  due 
to  fecal  impaction  which  occurs  in  anemic  patients  who  have  long  been 
suffering  from  chronic  intestinal  catarrh.  The  onset  is  gradual,  it  is 
preceded  by  constipation  which,  though  obstinate,  is  not  inveterate,  often 
by  constipation  alternating  with  diarrhea.  When  the  blockage  becomes 
complete,  distention  and  hyperperistalsis  are  both  marked,  and  vomiting 
is  recurrent  and  the  constipation  absolute.  The  usual  position  of  fecal 
impaction  is  in  the  rectum  where  it  can  be  felt  by  digital  examination. 
If  in  the  colon,  a  doughy  mouldable  tumor  may  be  detected. 

Obturation  by  gallstone  (rare)  gives  a  preceding  history  of  crippling 
peritonitis  in  the  gall-bladder  region. 

Obstruction  due  to  foreign  body  may  be  diagnosticated  by  the  history 
and  at  times  by  the  skiagraph. 

Complete  obstruction  due  to  stricture  formation  or  to  pressure  of  a 
tumor  or  infiltration  in  the  bowel  wall,  or  external  to  it,  is  preceded  by  a 
history  of  repeated  attacks  of  partial  obstruction,  and  often  before  this 
the  symptoms  of  the  causative  lesion.  Since  the  obstruction  is  slow  in 
its  development,  the  muscular  coat  of  the  bowel  lying  above  the  seat  of 
narrowing  hypertrophies,  and,  if  time  be  given,  the  gut  dilates.  The 
peristalsis  in  this  segment  is  usually  both  palpable  and  visible,  and,  par- 
ticularly in  the  case  of  stricture,  is  attended  by  annoying  borborygmus. 

Obstruction  due  to  angulation  of  the  bowel,  incident  to  adhesion, 


INTESTINAL  OBSTRUCTION  483 

corresponds  in  type  to  obstruction  without  strangulation.  The  sudden 
painful  onset  is  without  pronounced  shock.  The  major  complaint  is  of 
severe  recurring  colicky  pain,  and  often  vomiting,  usually  with  remissions 
or  complete  intermissions,  since  the  obstruction  is,  as  a  rule,  not  per- 
sistently complete.  Except  when  the  sigmoid  is  involved,  the  history  of 
a  previous  operation  or  a  local  peritonitis  is  usually  obtained.  This 
form  of  ileus  is  frequently  observed  as  an  early  sequel  to  abdominal 
operation,  particularly  when  drainage  has  been  needful. 

Strangulation  Ileus. — Mechanical  obstruction  of  the  bowel  lumen 
may  be  complicated  by  a  devitalizing  constriction  of  its  bloodvessels, 
in  which  case  it  is  called  strangulation  ileus.  This  is  usually  due  to 
constriction  of  the  gut  by  a  hernial  orifice.  A  similar  constriction  may 
be  caused  by  fibrous  bands  incident  to  a  former  peritonitis,  Meckel's 
diverticulum,  appendicular  or  omental  adhesions  or  openings  in  the 
mesentery  or  omentum. 

With  the  onset  of  the  symptoms  of  strangulation  ileus,  especially  if 
these  come  on  shortly  after  a  violent  muscular  effort,  the  hernial  orifices 
should  be  carefully  examined;  this  is  especially  important  if  there  is  a 
history  of  previously  existing  hernia.  In  the  case  of  strangulated  iliac 
or  obturator  hernia  there  will  be  no  tumor,  but  local  pain  and  tenderness 
and  radiations  of  pain  may  be  suggestive. 

In  the  absence  of  the  signs  of  external  hernia  the  possibility  of  dia- 
phragmatic, duodenojejunal,  and  retroperitoneal  hernise  should  be 
considered.  The  chest  signs  of  diaphragmatic  hernia  may  be  character- 
istic (see  p.  507).  Strangulation  of  other  internal  hernise  cannot  be 
diagnosticated  as  such. 

The  characteristic  symptoms  of  strangulation  ileus  are  sudden,  violent, 
agonizing,  general  abdominal  pain,  usually  associated  with  shock,  imme- 
diate nausea,  and  vomiting,  the  latter  persistently  recurring,  and  a 
temporary  diminution  or  complete  cessation  of  peristalsis  (reflex). 
With  recovery  from  shock  peristalsis  becomes  reestablished  and  palpably, 
audibly,  and  sometimes  visibly  exaggerated,  and  there  is  often  an  urgent 
desire  to  defecate,  the  efforts  producing  at  the  most  one  or  two  bowel 
movements. 

Tympany  shortly  develops,  demonstrable  first  in  the  strangulated  gut 
segment,  later  becoming  general  above  the  point  of  obstruction,  the  gut 
below  remaining  undistended.  The  shocking  pain  of  onset  becomes 
more  bearable  and  colicky  in  nature,  exhibiting  remissions  and  exacer- 
bations incident  to  peristalsis.  Constipation  shortly  becomes  absolute. 
Vomiting  is  recurring,  straining,  and  propulsive  at  first;  later,  with  the 
onset  of  peritonitis,  it  becomes  regurgitant  and  effortless.  The  constitu- 
tional symptoms  are  those  of  intestinal  toxemia.  The  onset  of  gangrene, 
often  characterized  by  a  temporary  diminution  of  pain,  is  followed  by  the 
rapid  development  of  the  symptoms  of  diffuse  peritonitis. 

At  times  strangulation  ileus  in  onset  and  progress  corresponds  so 
closely  with  that  characteristic  of  obturation  that  a  diagnosis  is  formu- 
lated only  on  operation  or  by  the  development  of  acute  diffuse  peri- 
tonitis. 


484  THE  ABDOMEN 

The  distinction  between  internal  strangulation  and  acute  diffuse 
peritonitis  from  perforation  is  dependent  upon  the  prompt  reaction  from 
shock  in  strangulation,  the  exaggerated  peristalsis  incident  to  this 
recovery,  the  explosive  vomiting,  and  the  absence  of  general  abdominal 
rigidity  and  extreme  tenderness.  The  preceding  history  is  usually 
helpful.  During  the  primary  shock  period  a  differential  diagnosis  cannot 
be  made. 

In  distinguishing  between  strangulation  and  the  reflex  dynamic  ileus 
incident  to  pulmonary,  renal  or  cardiac  affections,  spinal  degeneration, 
particularly  ataxia,  arteriosclerosis,  renal  and  biliary  colic,  aside  from 
the  symptoms  particularly  characteristic  of  each  of  these  conditions,  the 
moderate  primary  tympany  usually  not  actively  progressive,  the  feeble  or 
absent  peristalsis,  and  the  cessation  of  constantly  recurring  vomiting, 
with  the  subsidence  of  the  agonizing  pain,  are  characteristic.  Moreover, 
purgatives  given  in  full  doses  are  usually  efficient.  In  acute  mechanical 
obstruction  their  one  useful  purpose  is  to  so  aggravate  symptoms  that 
previously  unwilling  patients  welcome  surgical  treatment. 

Intussusception,  or  invagination  of  one  portion  of  the  gut  within 
another,  usually  downward  and  in  the  ileocolic  region,  essentially  an 
affection  of  infancy  and  childhood,  and  the  usual  cause  of  acute  intes- 
tinal obstruction  at  this  age,  is  frequently  caused  by  a  polyp,  sometimes 
follows  abdominal  trauma,  and  is  an  occasional  sequel  or  accompani- 
ment of  diarrhea  and  dysentery.  It  may  develop  in  the  midst  of  perfect 
health. 

Because  the  bowel  is  usually  not  completely  occluded  and  the  constric- 
tion not  immediately  devitalizing^  intussusception  departs  from  the  type 
of  strangulation  in  that  it  is  usually  characterized  by  tenesmus  and 
straining  and  the  frequently  repeated  passage  of  bloody  mucus  with  a 
fecal  admixture;  the  primal  shock  is  slight,  the  vomiting  not  constantly 
recurring,  and  meteorism  is  slow  in  development.  Colicky  pain  with 
remissions  of  minutes  or  hours  and  exaggerated  peristalsis,  are  usually 
associated  with  the  detection  of  a  soft  tumor  placed  along  the  course  of 
the  colon.  At  times  the  invagination  can  be  felt  by  rectal  examina- 
tion. 

When  there  is  no  palpable  tumor,  the  diagnosis  from  acute  or  sub- 
acute gastro-enteritis  should  be  based  upon  the  complete  absence  of 
stools,  or  the  passage  of  bloody  mucus  containing  at  most  a  very  slight 
fecal  admixture. 

Acute  Volvulus. — Acute  volvulus,  or  twisting  of  the  intestine  upon  its 
mesentery  as  a  base,  may  involve  nearly  the  whole  of  the  small  gut,  or  one 
or  more  loops  of  it.  Usually  it  is  observed  in  the  sigmoid  of  constipated 
elderly  people,  and  is  distinguished  in  addition  to  the  symptoms  common 
to  all  forms  of  strangulation  by  a  rounded,  tympanitic,  quiet  tumor, 
which  may  be  felt  in  the  left  flank  or  may  extend  above  the  umbilicus 
and  beyond  the  median  line.  There  is  usually  absolute  constipation, 
pronounced  tenesmus,  and  diminished  capacity  to  rectal  injection.  The 
symptoms  may  be  sudden  in  onset  or  may  have  been  preceded  by  recur- 
ring attacks  of  partial  obstruction. 


GASTRO-ENTERITIS  485 


GASTRO-ENTERITIS. 


Catarrhal  inflammation  of  the  stomach  and  bowels  frequently  simulates 
surgical  afi^ections  of  these  organs  and  complicates  many  of  them. 

Acute  Gastritis. — Acute  gastritis  is  characterized  by  epigastric  tender- 
ness, distress  or  pain  aggravated  by  eating,  nausea,  eructations  and 
vomiting  of  undigested  food  or  of  mucus  sour  from  butyric,  lactic,  or 
other  acid  fermentation  unless  there  be  bile  admixture.  In  severe  cases 
the  vomitus  contains  blood.  Headache,  constipation,  foul  breath,  and 
coated  tongue  are  associated  symptoms.     Children  exhibit  fever. 

Acute  Enteritis. — Acute  enteritis  is  characterized  by  colic,  which  may  be 
agonizing  in  intensity,  but  is  rarely  accompanied  by  shock,  general 
abdominal  tenderness,  exaggerated  peristalsis,  and  diarrhea,  excepting 
when  the  process  is  confined  to  the  duodenum.  The  evacuations  are 
foul,  bilious,  mucoid,  at  times  bloody,  and  are  copious  and  recurring  in 
proportion  to  the  colonic  involvement.  Moderate  tympany  is  usual,  and 
is  least  marked  when  the  diarrhea  is  profuse.  The  same,  with  some 
modification,  is  true  of  fever. 

\^^len  the  inflammation  is  conflned  to  the  duodenum  it  is  not  infre- 
quently associated  with  jaundice  unattended  by  colic  and  usually  of 
brief  duration  (days).  The  greatest  tenderness  is  above  and  to  the 
right  of  the  umbilicus.  It  is  from  this  source  that  infection  of  the 
biliary  passages  usually  arises.  Ileocolitis  is  characterized  by  pain 
and  tenderness,  most  pronounced  in  the  right  iliac  fossa  and  along  the 
■course  of  the  colon,  and  copious  and  frequent  fluid  passages,  containing 
large  quantities  of  mucus.  The  complication  of  appendicitis,  which  is 
not  unusual,  is  characterized  by  the  substitution  of  constipation  for 
diarrhea,  of  fixation  rigidity  by  protective  contraction  of  the  right  rectus 
muscle. 

Sigmoiditis  and  proctitis  are  attended  with  pain,  tenderness  in  the  left 
iliac  fossa,  with  burning,  teasing,  and  often  tormenting  tenesmus  resulting 
in  small  mucoid,  frequently  bloody  evacuations.  The  diagnosis  can  at 
times  be  made  by  a  proctoscopic  examination. 

Chronic  gastritis  and  enteritis  are  usually  associated.  The  combined 
affection  is  characterized  by  eccentricities  of  appetite  or  its  complete  loss, 
belching  and  rectal  passage  of  flatus  with  much  borborygmus,  or  even 
vomiting,  particularly  in  the  morning  or  some  hours  after  the  ingestion 
of  food.  Except  in  that  form  of  chronic  gastritis  accompanying  ulcer, 
or  in  certain  neuroses,  hydrochloric  acid  is  either  diminished  or  absent. 
In  chronic  gastritis  constipation  is  usual. 

In  chronic  colonic  catarrh,  diarrhea  is  the  rule.  The  stools  are  offen- 
sive and  contain  mucus.  Pain  and  tenderness  may  be  absent,  insignifi- 
cant or  periodically  harassing.  The  colic  is  likely  to  be  recurring.  The 
tenderness  can  usually  be  elicited  by  deep  palpation  in  the  region  of 
maximum  involvement.  There  is  usually  gastric  and  intestinal  tym- 
pany, excepting  shortly  after  attacks  of  vomiting  and  purging,  and  the 
noisy  belly  of  an  active  peristalsis  working  on  gaseous  and  liquid  contents. 


486  THE  ABDOMEN 

Foul  breath,  flabby,  coated  tongue,  chronic  pharyngitis,  and  the  general 
systemic  condition  incident  to  chronic  intestinal  toxemia  are  observed. 
The  urine  is  diminished  and  contains  an  excess  of  indican. 

Chronic  obstruction  from  any  cause  is  attended  with  the  symptoms 
of  gastritis  or  enteritis  dependent  on  its  position,  together  with  those 
of  interference  with  the  onward  passage  of  the  intestinal  contents. 
Obstinate  constipation  alternating  with  diarrhea,  and  associated  with 
local  pain  and  tenderness,  and  a  neurasthenic  condition  are  highly  char- 
acteristic of  the  association  of  symptoms  in  the  case  of  chronic  sigmoid- 
itis dependent  on  redundancy  and  angulation. 

Before  assigning  a  surgical  cause  to  gastro-enteritis  it  is  necessary  to 
eliminate  the  general  medical  causes  of  this  affection,  among  which  may 
be  mentioned  dietetic  errors  characterized  by  simple  catarrh,  cholera 
morbus,  or  ptomain  poisoning,  local  expressions  of  the  exanthemata, 
gout,  purpura,  scurvy,  uremia,  generally  associated  with  constipation, 
sepsis  of  any  kind,  or  intestinal  parasites. 

Gastro-enteritis  dependent  upon  infiltration,  ulcer,  visceral  prolapse, 
cicatricial  contracture,  or  partial  obstruction  from  any  cause  is  distinctly 
surgical  and  calls  for  surgical  treatment.  The  symptoms  of  the  causative 
factor  can  usually  be  found  if  carefully  sought  for.  It  should  be  remem- 
bered that  chronic  gastro-enteritis  may  be  characterized  by  abdominal 
pain,  nausea,  vomiting,  or  diarrhea. 

ABDOMINAL  TUMORS. 

The  diagnosis  of  abdominal  swelling  is  dependent  upon  the  point  of 
origin  of  such  swelling,  its  nature,  whether  gaseous,  fluid,  or  solid,  and 
in  the  latter  case  whether  hyperplastic,  inflammatory,  or  neoplastic;  its 
mobility,  its  extent,  its  relation  to  systemic  conditions  or  organic  lesions. 

In  forming  an  opinion  the  condition  of  general  nutrition,  the  rapidity 
of  development,  antecedent  disease,  and  the  age  of  the  patient  are  all 
factors  to  be  considered,  nor  can  the  examination  be  regarded  as  complete 
without  a  record  of  the  urine,  blood,  the  daily  temperature  range,  the 
pulse  rate,  and  often  the  data  derived  from  fecal  examination. 

In  general  terms  acute  or  subacute  abdominal  inflammation  is  char- 
acterized, in  addition  to  swelling,  by  the  blood  changes  and  tempera- 
ture reaction  which  are  incident  to  this  condition  in  other  parts  of  the 
body.  These  symptoms,  when  marked,  associated  with  local  tenderness 
and,  in  cases  of  peritoneal  or  intraperitoneal  involvement,  muscular 
rigidity  establish  the  diagnosis. 

Chronic  inflammation  is,  however,  at  times  characterized  by  such 
slightly  marked  constitutional  and  local  symptoms  of  this  condition  as 
to  be  entirely  misleading.  Under  such  circumstances  the  tumor  is  the 
major  symptom,  together  with  toxic  anemia  and  perhaps  slight  tempera- 
ture fluctuations  not  greater  than  are  frequently  observed  in  malignant 
disease. 

The  diagnosis  must  often  be  made  by  operation.  Sometimes  even  then 
it  is  decided  only  by  microscopic  examination  of  the  tissue  removed. 


ABDOMINAL  TUMORS  487 

The  detection  of  intra-abdominal  tumors  by  palpation  is  particularly 
difficult  in  patients  with  muscular  and  rigid  belly  walls,  in  those  who  are 
chronically  tympanitic,  in  those  cursed  by  an  enormous  adipose  panniculus, 
or  in  those  suffering  from  ascites. 

Examination  for  abdominal  tumor  should  be  preceded  by  a  thorough 
evacuation  of  the  bowels  and  by  emptying  the  bladder. 

Neoplasms  involving  the  parietes  are  usually  accidentally  discovered 
by  the  patient,  and  are  readily  detected  by  inspection  or  palpation,  or 
both.  The  true  nature  of  such  growth  is  usually  determined  by  opera- 
tion, though  the  rapidity  of  growth  and  age  incidence  are  both  important 
factors  in  framing  an  opinion. 

The  presence  of  intra-abdominal  neoplasms  is  usually  not  suspected 
until  by  their  growth  they  produce  pressure  symptoms,  as  a  rule  those 
of  chronic  intestinal  obstruction.  Occasionally  they  are  detected  by 
palpation  before  such  pressure  symptoms  develop. 

Cysts,  if  tense  and  thick-walled,  cannot  be  distinguished  by  palpation 
from  solid  tumors,  though,  when  they  reach  large  size,  they  usually 
exhibit  distinct  fluctuation.  \\Tien  soft  walled  and  flaccid,  their  detection 
may  be  quite  impossible  except  by  means  of  an  exploration. 

Swellings  Limited  to  the  Abdominal  Wall. — Such  swellings  are 
characterized  by  their  superficial  position,  obvious  both  to  palpation 
and  inspection,  and  the  absence  of  symptoms  referable  to  involvement 
of  internal  organs.  If  the  abdominal  walls  are  lax,  the  mass  can  be 
grasped  between  the  thumb  and  finger  or  between  the  two  hands,  and 
thus  differentiated  from  the  abdominal  contents.  They  have  neither 
respiratory  nor  other  movement  independent  of  the  abdominal  wall, 
except  in  the  case  of  hernia.  Contraction  of  the  abdominal  muscles 
does  not  flatten  the  tumor  or  cause  it  to  disappear,  but  often  accentuates  it. 

From  an  intra-abdominal  tumor  fixed  to  the  parietal  peritoneum  the 
distinction  may  be  difiicult. 

Diffuse  swelling  of  the  abdominal  wall  is  rarely  limited  to  this  region, 
though  it  may  be  most  marked  here.     The  umbilicus  is  usually  drawn  in. 

The  diffuse  swelling  due  to  obesity  does  not  pit  on  pressure,  gives 
the  characteristic  finely  lobulated  sensation  of  fat  to  the  palpating  fingers, 
and  exhibits  the  characteristic  transverse  folds  at  the  umbilicus  and  just 
above  the  pubes. 

Edema  pits  on  pressure  and,  except  as  an  expression  of  local  inflam- 
mation, is  not  confined  to  the  abdominal  wall. 

Emphysema  exhibits  crackling  and  pitting  on  palpation,  and  is  asso- 
ciated with  fractured  rib  or  gangrenous  cellulitis. 

Cellulitis,  usually  due  to  extravasated  urine,  is  preceded  by  a  history 
of  urethral  obstruction,  is  attended  by  a  pronounced  edematous  scrotal 
swelling,  is  limited  in  its  downward  extension  by  Poupart's  ligament,  pits 
on  pressure,  and  exhibits  the  constitutional  symptoms  of  profound  sepsis. 

Circumscribed  Swellings  of  the  Abdominal  Wall.— The  commonest 
parietal  swelling  is  that  due  to  hernia  usually  occurring,  in  the  absence 
of  preceding  woimd  or  severe  trauma,  in  the  inguinal  or  umbilical  region 
or  in  the  midline  above  or  below  the  umbilicus,  and  exhibiting  the  char- 


48'8  THE  ABDOMEN 

acteristic  features  of  this  condition  (see  p.  500).  The  midline  hernise 
are  usually  small  (the  size  of  a  finger  tip),  and  can  be  distinguished  from 
a  projection  of  the  subperitoneal  fat  through  the  linea  alba  only  by 
operation,  since  either  condition  may  be  reducible  and  give  slight 
impulse  on  coughing.  These  hernise  often  cause  persistently  recurring 
gastro-intestinal  symptoms. 

Abscess  of  the  abdominal  parieteSj  if  acute,  presents  the  characteristic 
symptoms  of  this  condition.  It  is  usually  secondary  to  intra-abdominal 
suppuration,  particularly  of  the  appendix,  and  is  preceded  by  symptoms 
characteristic  of  local  suppurative  peritonitis. 

Spinal  osteomyelitis  may  lead  to  extensive  pus  formation  in  the 
abdominal  walls. 

Tuberculous  bone  infection  usually  causes  a  cold  abscess,  the  dominant 
symptom  of  which  is  a  fluctuating,  non-sensitive,  slowly  progressive, 
painless  tumor.     A  favorite  seat  of  pointing  is  in  the  lumbar  region. 

Actinomycosis  due  to  direct  extension  from  the  intestine,  and  noted, 
as  a  rule,  in  the  ileocecal  region,  is  characterized  by  the  progressive 
involvement  of  the  parietes  in  an  induration  which  softens  and  discharges 
pus  and  which  contains  the  ray  fungus. 

A  similar  condition  may  result  from  tuberculosis,  nor  can  the  diagnosis 
be  made  except  by  microscopic  examination  and  associated  manifesta- 
tions of  the  disease. 

Rupture  of  the  Abdominal  Muscles. — ^Rupture  of  the  abdominal  muscles, 
commonly  involving  the  rectus,  and  observed  in  the  late  course  of  diseases 
such  as  typhoid,  though  it  has  been  reported  in  healthy  individuals  as 
the  result  of  severe  strain,  is  characterized  by  sudden  severe  pain,  rapid 
(minutes)  tumor  formation  which  may  reach  great  size,  and  the  detec- 
tion of  a  break  in  continuity  by  palpation,  though  intraparietal  bleeding 
in  the  absence  of  the  last  sign  would  be  suflBciently  characteristic. 

Syphilis. — Syphilis  in  the  form  of  gumma  (rare)  closely  simulates 
malignant  infiltration.  A  history  of  infection  and  the  presence  of  asso- 
ciated lesion,  or  the  evidence  of  such  in  the  past,  and  the  application  of 
the  therapeutic  test  are  diagnostic  helps. 

Lipoma. — Of  the  benign  tumors,  lipoma  is  the  one  most  frequently 
encountered;  unmistakable  in  its  superficial  form,  the  diagnosis  is 
suggested  by  its  extremely  slow  growth  (years)  and  absence  of  symp- 
toms other  than  bulk.  When  subaponeurotic,  the  diagnosis  is  more 
difficult,  but  would  be  suggested  by  its  softness  and  its  gradual  develop- 
ment. 

Lipomata  at  the  midline  are  generally  above  the  umbilicus.  They 
originate  in  the  preperitoneal  fat,  projecting  along  the  course  of  a  blood- 
vessel through  the  aponeurosis  until  they  become  subcutaneous.  These 
lipomata  are  often  reducible;  they  not  infrequently  drag  a  pouch  of 
peritoneum  with  them,  thus  forming  a  true  hernia. 

Fibroma. — Fibroma,  single  or  multiple,  developing  in  the  lower  quad- 
rants, particularly  from  the  rectus  sheath  of  women  who  have  borne  many 
children,  and  often  first  noticed  during  pregnancy,  are  characterized  by 
their  hardness  and  slow  (years)  growth. 


ABDOMINAL  TUMORS  489 

Phantom  Tumor. — Phantom  tumor  observed  in  hysterical  women, 
usually  near  the  midline  below  the  umbilicus,  and  due  to  muscular 
contraction,  forms  a  smooth,  non-sensitive  mass,  which  is  not  flattened 
or  made  less  conspicuous  by  muscular  contraction  and  does  not  move 
independently  of  the  muscle.     It  disappears  during  deep  ether  anesthesia. 

Sarcoma. — Sarcoma,  at  times  of  traumatic  origin,  usually  apparently 
causeless,  is  marked  by  its  rapid  growth  (months) .  The  early  diagnosis 
should  be  based  upon  the  prompt  removal  and  microscopic  examination 
of  a  recently  discovered  and  steadily  progressive  parietal  tumor. 

Carcinoma  is  usually  secondary. 

Cyst  of  the  urachus,  due  to  a  persistent  patulousness  of  a  part  of  this 
canal,  is  most  frequent  in  males.  A  fixed  midline  tumor  between  the 
navel  and  symphysis,  sometimes  varying  in  size  proportionate  to  the 
fulness  of  the  bladder,  exceptionally  reaching  huge  size,  is  characteristic 
of  this  condition. 

Hydatid  cyst  (rare),  noted  in  the  midline  below  the  umbilicus  or  in 
the  lumbar  region,  forms  a  rounded,  slow  growing  (years)  tumor,  often 
solid  to  palpation.  The  diagnosis  is  usually  not  made  until  operation, 
though  fluctuation,  hydatid  thrill,  the  finding  of  hooklets  in  the  evacuated 
fluid,  and  the  precipitin  reaction  would  be  characteristic. 

The  Umbilicus. — ^The  umbilicus,  the  scar  of  the  obliterated  umbilical 
cord,  is  weakest  at  its  upper  part  (scar  of  the  obliterated  umbilical  vein). 
Its  lower  part  is  strengthened  by  the  remains  of  both  the  urachus  and 
umbilical  arteries. 

Pouting  umbilicus  is  usually  due  to  hernia  or  ascites.  It  is  occasion- 
ally caused  by  prolonged  gaseous  distention. 

Congenital  anomalies  occur  in  the  form  of  failure  of  the  lateral  plates 
to  properly  come  together  at  the  midline,  thus  leaving  the  abdominal 
contents  without  muscular  or  fascial  covering,  and  resulting  in  congenital 
umbilical  hernia;  also  there  may  be  persistence  of  the  urachus,  con- 
stituting a  urinary  fistula,  or  of  the  vitelline  duct,  constituting  a  fecal 
fistula. 

Persistent  vitelline  duct  is  characterized  by  a  pouting  of  mucous  mem- 
brane at  the  umbilicus  which  closely  resembles  a  small  prolapsed  anus. 
Through  the  opening  feces  may  or  may  not  be  discharged.  In  the  former 
instance  the  diagnosis  is  absolute.  In  the  latter  the  affection  must  be 
distinguished  from  patent  urachus. 

Persistent  urachus  results  in  the  formation  of  a  midline  cyst  which 
usually  bulges  somewhat  at  the  umbilicus  as  well  as  below  it,  or,  if  a 
fistula  or  pervious  urachus  is  present,  it  is  characterized  by  a  leakage  of 
urine  from  a  small  opening  in  the  lower  part  of  the  umbilical  scar. 

Myxoma  may  occur  in  the  umbilical  scar  of  infants  and  produce  a 
good-sized,  soft,  non-inflammatory  mass. 

Lipoma,  sarcoma,  and  gumma  occur  at  the  navel.  The  last  named, 
when  it  ulcerates  and  becomes  indurated,  must  be  differentiated  from 
malignant  tumor  by  the  history,  associated  lesions  or  their  scars  or  pig- 
mentations, and  the  therapeutic  test. 

Carcinoma  of  the  navel  may  originate  at  the  umbilicus  or  may  be 


490       '  THE  ABDOMEN 

secondary  to  cancer  of  the  stomach,  intestine,  or  liver,  of  which  it  often 
may  be  taken  as  evidence.  This  may  be  due  to  direct  extension  or 
metastasis  along  the  lymphatics.  The  diagnosis  is  made  by  incision 
and  microscopic  examination  of  a  fragment  of  tissue. 

Inflammatory  infiltration,  abscess,  and  eczema,  particularly  noted  in 
the  uncleanly,  exhibit  their  characteristic  symptoms  at  the  umbilicus. 
Diagnosis  is  not  difficult. 

General  Intra-abdominal  Swellings. — Tympanites. — ^Tympanites,  or 
gaseous  distention  of  the  intestines,  when  sufficiently  pronounced  and 
persistent  to  constitute  a  surgical  affection,  is  incident  to  a  paresis 
of  the  muscular  coats  of  the  stomach  and  bowel,  allowing  of  a  dilata- 
tion so  great  as  seriously  to  interfere  with  the  functions  of  both  respira- 
tion and  circulation.  The  full,  rounded  abdomen,  exhibiting  the 
pseudorigidity  of  tension,  the  obliteration  of  anatomical  irregularities 
of  the  surface,  universally  tympanitic  even  well  up  into  the  thorax, 
and  the  associated  dyspnea,  costal  breathing,  and  in  hyperacute  cases 
pulse  hurry,  are  characteristic. 

Tympany  in  its  congenital  form  appears  in  Hirschsprung's  disease, 
or  idiopathic  dilatation  of  the  colon,  and  may  be  so  marked  as  to 
overdistend  the  entire  abdomen,  pushing  the  other  hollow  viscera 
aside. 

Either  the  stomach  or  the  sigmoid,  if  greatly  distended,  produces  a 
degree  of  tympany  quite  similar  to  that  of  general  gastro-intestinal 
paresis. 

Diffuse  Peritoneal  Effusion. — Diffuse  peritoneal  effusion,  when  it 
reaches  such  a  degree  as  to  interfere  with  the  respiratory  or  circulatory 
functions,  becomes  a  surgical  affection  independent  of  its  cause. 

These  diffuse  effusions  are  characterized  in  their  early  development  by 
a  globular  belly,  peripherally  dull  on  percussion,  but  resonant  about  the 
navel.  Change  in  the  percussion  note  from  dull  to  resonant  occurs  on 
shifting  the  patient's  position.  Fluctuation  may  be  felt  in  one  flank 
when  the  other  is  jarred.  In  extreme  cases  the  umbilicus  forms  a  knob- 
like projection. 

The  effusion  may  be  serous,  serofibrinous,  or  purulent. 

Ascites,  or  serous  effusion,  if  unattended  by  general  dropsy,  is  usually 
dependent  upon  obstruction  to  the  portal  circulation  or  tuberculous 
peritonitis. 

Atrophic  cirrhosis  of  the  liver,  in  its  terminal  stage,  is  the  common 
cause  of  portal  obstruction  in  adults.  It  is  characterized  by  a  small 
liver,  often  not  demonstrable  as  such  until  the  fluid  has  been  withdrawn, 
and  a  characteristic  preceding  history. 

The  portal  obstruction  caused  by  multiple  serositis,  or  Pick's  disease, 
is  characterized  by  enlargement  of  the  liver  and  spleen,  adhesive  peri- 
carditis, heart  enlargement  and  usually  valvular  disease,  pleural  effu- 
sion, and  marked  ascites,  which  may  be  tapped  repeatedly  without 
deterioration  of  the  patient's  condition.  The  latter  fact  helps  to  distin- 
guish it  from  atrophic  cirrhosis. 

Cancer  of  the  liver  and  of  the  head  of  the  pancreas  may  produce 


ABDOMINAL  TUMORS  491 

similar  symptoms.  The  affection  is  rapidly  progressive,  other  pressure 
symptoms  usually  develop,  and,  if  the  liver  be  involved,  the  tumor 
often  can  be  felt. 

In  diffuse  carcinomatosis  the  fluid  removed  by  tapping  is  often 
blood-stained  and  contains  cancer  cells. 

Tuberculous  peritonitis,  commonest  in  the  first  three  decades,  the 
usual  cause  of  ascites  in  children,  may  be  without  symptoms  other 
than  the  swelling,  or  may  exhibit  slight  rigidity  and  tenderness  to  press- 
ure. In  any  form  it  is  attended  with  emaciation,  irregular  fever,  pulse 
hurry,  and  absence  of  leukocytosis.  The  fibrous  or  adhesive  variety 
is  characterized  by  slight  serous  effusion  and  the  formation  of  demon- 
strable masses  due  to  adhesion  of  the  intestinal  coils  and  thickening 
and  rolling  up  of  the  omentum.  The  ulcerative  variety  runs  a  rapid 
course  and  forms  a  purulent  exudate  which  is  nearly  always  localized. 

Ascites  attended  with  demonstrable  edema  is  usually  secondary  to 
disease  of  the  heart  or  kidney.  It  may  also  be  an  expression  of  pro- 
found anemia. 

The  distinction  between  diffuse  peritoneal  effusion  and  ovarian  cyst 
is  based  on  the  midline  dulness  and  flank  resonance  of  the  latter  con- 
dition, the  corroborative  results  of  vaginal  examination,  and  the  com- 
paratively slight  difference  in  the  area  of  percussion  dulness  and  reso- 
nance incident  to  change  in  posture.  An  enormous  hydronephrosis 
should  give  a  suggestive  previous  history,  nor  does  the  fluid  show  the 
same  mobility  as  that  of  diffuse  peritoneal  effusion. 

DifEuse  Blood  Effusions. — Diffuse  blood  effusions,  usually  traumatic, 
postoperative,  or  incident  to  rupture  of  ectopic  gestation,  are  character- 
ized by  the  symptoms  and  physical  signs  of  grave  hemorrhage,  rapidly 
formed  movable  dulness  in  the  flanks,  pain,  tenderness,  tympany,  and 
often  by  the  desire  to  urinate  and  to  defecate. 

Localized  Intra-abdominal  Swellings. — Swellings  of  the  midline 
or  near  it,  if  fixed,  are  usually  retroperitoneal  and  neoplastic  in  origin, 
those  of  the  upper  and  lower  right  quadrant  are  usually  inflammatory, 
and  those  of  the  upper  and  lower  left  quadrant  are  usually  neoplastic, 
while  those  of  the  lumbar  region  are,  as  a  rule,  renal,  perirenal,  or 
spinal  in  origin,  and  either  inflammatory  or  neoplastic.  To  these  rules 
there  are  many  exceptions. 

Midline  Swellings. — Midline  swellings  include  those  of  the  retro- 
peritoneal tissues,  the  body  of  the  pancreas,  the  left  lobe  of  the  liver, 
the  fundus  of  the  stomach,  the  transverse  colon,  the  omentum,  the 
small  intestines,  the  mesentery,  the  bladder  space,  and  the  uterus. 

The  retroperitoneal  midline  swellings,  if  they  reach  conspicuous 
size,  are  usually  of  the  lymphatic  glands  and  neoplastic;  sometimes 
they  are  inflammatory.  Aortic  or  iliac  aneurysm  appears  near  the 
midline,  as  do  lipomata  and  lymphatic,  chylous,  serous,  dermoid,  and 
hydatid  cysts. 

The  retroperitoneal  origin  of  the  swelling  is  suggested  by  its  deep 
seat,  though  on  light  palpation  it  may  seem  superficial,  its  slight  or 
absent  mobility,  often  its  distinct  conveyance  of  aortic  pulsation,  the 


492  THE  ABDOMEN 

obscuring  effect  incident  to  gaseous  distention  of  the  intestines,  and 
its  pressure  effects  as  shown  by  edema  of  the  lower  extremities,  pain 
radiating  downward,  gastro-intestinal  disturbances,  and  emaciation. 

Acute  inflammatory  affections  of  the  midhne  retroperitoneal  space 
are  distinguished  by  the  local  and  constitutional  symptoms  of  inflam- 
mation rather  than  by  those  of  tumor. 

Tuberculous  inflammation  exceptionally  forms  a  tumor  either  due 
to  cold  abscess,  secondary  to  bone  involvement,  or  incident  to  tuber- 
culous adenitis;  other  and  more  pronounced  symptoms  of  the  tubercu- 
lous process  are  usually  present. 

Malignant  infiltration,  commonly  sarcomatous,  exceptionally  pri- 
mary, usually  secondary  to  involvement  of  the  testicle,  ovary,  or  other 
organ  contributing  lymph  vessels  to  the  postperitoneal  lymphatic  chain, 
causes  a  rapidly  growing  (months)  nodular  tumor  which  usually  pre- 
sents the  typical  characteristics  of  postperitoneal  growths.  Because  of 
their  great  vascularity  and  of  the  pressure  they  exert  upon  the  artery, 
these  growths  exceptionally  give  both  bruit  and  expansile  pulsation, 
making,  in  the  absence  of  a  primary  peripheral  focus,  a  non-operative 
differential  diagnosis  difficult,  if  not  impossible. 

Retroperitoneal  cysts  (rare),  if  they  reach  large  size,  tend  to  grow 
between  the  mesenteric  layers.  Though  their  symptomatology  con- 
forms to  that  of  the  retroperitoneal  growths,  and  they  are  obscured  by 
inflation  of  the  gastro-intestinal  canal,  the  diagnosis  generally  has  been 
made  at  operation. 

Postperitoneal  lipoma  grows  forward  between  the  mesenteric  layers 
slowly  (years),  forming  a  large,  usually  soft,  semifluctuating  tumor, 
giving  midline  dulness  and  peripheral  resonance,  and  by  its  pressure 
causing  pain,  gastro-intestinal  disturbance,  and  emaciation.  The  dis- 
tinction from  postperitoneal  cyst  is  usually  made  by  operation. 

Aneurysm  of  the  aorta  or  the  iliac  arteries,  or  of  any  of  the  large 
branches  near  their  point  of  origin,  forms  a  postperitoneal  swelling 
which,  when  it  becomes  of  palpable  size,  usually  exhibits  the  character- 
istic symptoms  of  this  affection.  Exceptionally  the  distinction  from 
vascular  neoplasm  may  be  difficult. 

Swellings  of  the  body  of  the  pancreas  appear  as  midline  tumors 
in  the  epigastric  region.  They  are  distinguished  from  intraperitoneal 
tumors  by  their  fixation,  conveyance  of  aortic  pulsation,  and  obscuration 
by  gastric  inflation.  The  induration  of  chronic  pancreatitis  may  be 
detected  in  thin  persons.  Pancreatic  cysts  present  anteriorly  either 
above  or  below  the  stomach.  Cancer  of  the  body  of  the  gland  forms 
an  elongated  nodular  tumor,  which  cannot  be  distinguished  by  palpa- 
tion from  a  similar  infiltration  of  the  posterior  stomach  wall. 

Effusion  of  blood  or  serum  into  the  lesser  peritoneal  cavity,  usually 
secondary  to  acute  hemorrhagic  pancreatitis,  forms  an  epigastric  mid- 
line swelling  usually  masked  by  the  gastric  distention,  tenderness,  and 
rigidity  of  acute  peritonitis.  Later,  when  this  effusion  becomes  puru- 
lent, a  distinct  fixed  tumor  is  formed  and  is  accompanied  by  character- 
istic inflammatory  symptoms. 


ABDOMINAL  TUMORS  493 

Midline  intraperitoneal  swellings  are  from  the  left  lobe  of  the  liver, 
the  stomach,  the  transverse  colon,  the  mesentery,  the  omentum,  the 
uterus,  and  the  urinary  bladder. 

Tumors  from  the  liver  exhibit  the  freest  respiratory  movement.  If 
inflammatory,  the  local  and  constitutional  signs  of  this  condition  are 
commonly  present.  Gumma  must  be  distinguished  by  the  history 
and  the  therapeutic  test.  Cancer  is  a  late  manifestation  of  involve- 
ment elsewhere. 

Tumors  of  the  stomach,  in  the  absence  of  adhesions,  give  a  respiratory 
excursion  and  are  freely  movable,  and  if  of  the  anterior  wall  or  greater 
curvature,  are  made  more  pronounced  by  inflation.  The  nature  of 
the  tumor  must  be  determined  by  other  symptoms,  since  by  palpation 
the  distinction  between  chronic  indurated  ulcer  and  carcinoma  cannot 
be  framed,  nor  by  the  sense  of  touch  can  an  infiltration  of  the  posterior 
wall  be  distinguished  from  pancreatic  involvement  when,  as  is  common, 
adhesions  have  formed. 

Palpable  tumors  of  the  pylorus,  usually  neoplastic,  sometimes  inflam- 
matory, are  usually  found  slightly  to  the  right  of  the  midline,  and  between 
the  ensiform  process  and  the  umbilicus.  They  are  freely  movable, 
particularly  toward  the  left,  exhibit  respiratory  excursion,  and  are 
pushed  downward  and  to  the  right  on  inflation. 

Abscess  resulting  from  the  slow  perforation  of  a  gastric  ulcer  is  char- 
acterized by  inflammatory  symptoms  rather  than  those  of  tumor,  except 
when  it  involves  the  abdominal  wall  in  front. 

Gumma  and  benign  tumors  of  the  stomach  are  rare. 

Midline  swelling  of  the  colon  (rare),  usually  malignant,  is  character- 
ized by  free  mobility  and  superficial  position. 

Omental  swellings  may  present  in  the  midline  or  well  to  either  side. 
They  are  characterized  by  their  superficial  position  and  the  readiness 
with  which  they  contract  adhesions  to  the  parietal  peritoneum. 

Hematoma  of  the  omentum,  usually  postoperative  or  traumatic, 
exceptionally  spontaneous,  exhibits  a  tumor  of  rapid  (hours)  develop- 
ment, superficial  to  the  intestines,  and  attended  with  the  symptoms  of 
a  mild  local  peritonitis. 

Torsion  of  the  omentum  is  characterized  by  the  formation  of  a  tumor 
(hours  or  days),  with  the  symptoms  of  a  diffuse  peritonitis,  giving, 
however,  less  primal  shock,  and  exhibiting  much  slower  progress  than 
peritonitis  of  the  perforative  type. 

Diffuse  tuberculous  peritonitis,  except  that  of  the  serous  type,  is 
usually  characterized  by  an  enormously  thickened  adherent  omentum 
which  in  its  conformation  and  consistency  may  closely  simulate  an 
enlarged  and  displaced  kidney  or  spleen.  Other  characteristic  symp- 
toms of  tuberculous  involvement  are  usually  present. 

The  omental  seat  of  cysts  and  tumors  might  be  suggested  by  the 
demonstrable  fact  that  they  lie  superficial  to  the  intestines.  Diagnosis 
should  be  made  by  operation. 

Mesenteric  cysts,  generally  chylous,  may  lie  in  the  midline  or  at 
9,  considerable   distance   from    it.     They    are   usually  freely  movable, 


494  THE  ABDOMEN 

rounded  in  shape,  are  of  sufficient  consistency  to  suggest  a  displaced 
spleen  or  kidney,  and  are  diagnosticated  at  operation. 

Swellings  of  the  bladder  may  lie  either  in  the  midline  or  to  one  side 
of  it.  Either  by  percussion  or  palpation,  usually  both,  the  swelling 
can  be  traced  into  the  pelvis.  The  common  cause  for  such  swelling 
is  overdistention,  a  symptom  of  which  is  constant  dribbling.  Com- 
bined rectal  and  suprapubic  palpation  will  establish  the  diagnosis,  or, 
if  this  be  unconvincing,  the  passage  of  a  catheter. 

Tumors  of  the  bladder,  usually  malignant  when  large  and  involving 
its  upper  portion,  are  often  felt  by  suprapubic  palpation. 

Urachus  cysts  and  abscess  of  the  space  of  Retzius  form  extra  peri- 
toneal midline  tumor  which  may  be  difficult  to  distinguish  from  those 
lying  within  the  peritoneum. 

Abscess  of  the  space  of  Retzius,  usually  secondary  to  prostatic 
infection,  causes  a  hard,  tender  swelling  behind  the  pubic  symphysis, 
which  in  its  development  may  extend  as  high  as  the  umbilicus;  it  is 
attended  with  the  constitutional  symptoms  of  suppuration. 

Abscess  of  Douglas'  cul-de-sac,  when  it  reaches  large  size,  is  prone 
to  form  a  midline  suprapubic  swelling.  The  symptoms  of  local  peri- 
tonitis and  the  results  of  combined  rectal  and  suprapubic  palpation 
establish  the  diagnosis. 

The  womb,  if  enlarged  from  pregnancy  or  pathological  cause,  exhibits 
a  midline  swelling  which  can  be  traced  into  the  pelvis  and  the  seat  of 
which  is  determined  by  bimanual  palpation. 

Swellings  of  the  Right  Upper  Quadrant  of  the  Abdomen. — ^These  are 
usually  of  the  liver,  gall-bladder,  renal,  or  suprarenal  origin. 

The  acute  inflammatory  swellings  are  distinguished  from  the  hyper- 
plastic retention  or  neoplastic  enlargements  by  local  tenderness  and 
rigidity  and  the  constitutional  symptoms  of  acute  infection.  In  chronic 
infections  the  diagnosis  must  often  be  made  on  the  basis  of  the  history 
or  by  exploratory  operation.  The  swellings  of  the  liver  can  be  felt  to 
be  continuous  with  this  organ  and  exhibit  its  respiratory  motion. 

Floating  liver,  usually  observed  in  women  and  associated  with  pro- 
nounced visceral  proptosis,  is  recognized  by  the  normal  conformation 
and  size  of  the  organ  and  its  free  mobility  and  the  ease  with  which  it 
can  be  pushed  into  its  normal  position. 

The  enlargement  of  hypertrophic  cirrhosis  or  amyloid  degeneration, 
or  of  Banti's  disease,  is  diffuse,  symmetrical,  and  freely  movable,  and 
associated  with  other  characteristic  symptoms  of  these  conditions. 

The  enlargement  incident  to  syphilis  may  be  fixed  and  exceedingly 
painful  and  tender. 

RiedeVs  lohe,  usually  observed  in  women,  and  often  in  connection 
with  stone  in  the  gall-bladder,  forms  a  tongue-like  projection  down- 
ward which  cannot  be  distinguished  from  tumor  by  palpation,  except 
for  its  smooth,  non-nodular  surface.  In  itself  it  causes  no  symptoms. 
Corset  liver  forms  a  smooth,  painless,  superficially  placed  tumor,  exhibit- 
ing the  respiratory  movements  of  the  liver,  and  usually  showing  an 
obvious  connection  with  this  organ.     It  does  not  present  in  the  flank. 


ABDOMINAL  TUMORS  495 

Subphrenic,  abscess  of  the  right  side,  usually  secondary  to  appen- 
dicitis or  to  suppuration  of  the  liver  or  gall-bladder,  or  of  the  perirenal 
space,  may  form  a  demonstrable  tumor  by  pushing  the  liver  down- 
ward, and  by  extending  upward,  causing  a  dome  of  percussion  dulness, 
or,  if  the  abscess  contains  gas,  one  of  hyperresonance.  Constitutional 
symptoms  of  acute  or  chronic  infection  are  present,  usually  severe 
local  pain  and  tenderness,  and  often  a  complicating  serous  or  purulent 
pleuritis. 

Given  the  history  of  an  abdominal  infection  no  longer  active,  the 
continuance  of  sepsis  not  otherwise  to  be  accounted  for,  local  pain  and 
tenderness,  and  an  increase  in  the  area  of  liver  dulness,  the  diagnosis 
should  be  made  by  exploratory  incision. 

Liver  Abscess. — The  tender,  swollen  liver  of  acute  cholangitis  or 
multiple  abscess  is  a  minor  symptom  as  compared  with  the  constitutional 
symptoms  of  profound  sepsis.  Single  abscess,  usually  placed  near  the 
upper  surface  of  the  right  lobe,  is  rarely  recognized  as  a  tumor  until 
parietal  adhesions  have  formed  when  tenderness,  edema,  and  later 
fluctuation,  combined  with  pressure  symptoms  or  chronic  sepsis,  call 
for  incision  and  drainage. 

Echinococcus  cyst,  having  by  preference  the  liver  as  its  seat  of  lodge- 
ment, when  it  becomes  large  enough  to  be  palpable,  forms  a  smooth 
rounded  tumor  which  may  give  fluctuation  or  may  seem  solid.  It  is 
of  slow  growth  (months,  years),  and  in  the  absence  of  inflammation  or 
pressure  upon  bile  ducts  or  large  bloodvessels,  causes  no  symptoms. 
When  it  suppurates  the  symptoms  are  those  of  abscess.  The  hydatid 
tremor  is  neither  commonly  present  nor  is  it  diagnostic  when  found. 
The  absolute  diagnosis  should  be  made  by  exploratory  operation. 

Other  cysts  present  the  symptomatology  of  echinococcus  cyst  nor  can 
the  differential  diagnosis  be  made  without  operation  and  often  micro- 
scopic examination. 

Carcinoma  of  the  liver  forms  a  tumor  or  tumors  characterized  by 
dense  nodular  surface,  usually  secondary  to  malignant  growth  else- 
where, particularly  of  the  alimentary  tract,  and  of  the  breast,  multiple, 
and  accompanied  by  profound  cachexia. 

Primary  carcinoma  (rare)  of  the  liver,  when  it  forms  a  palpable 
tumor,  can  be  recognized  as  such  only  by  the  careful  exclusion  of 
syphilis  and  of  the  existence  of  a  primary  focus  elsewhere.  Its  diag- 
nosis is  of  importance,  since  it  is  amenable  to  surgical  operation. 

Ascites  and  jaundice  develop  only  if  the  neoplasm  in  its  growth  causes 
pressure  upon  the  portal  vein  or  on  the  bile  ducts. 

Gumma  of  the  liver  forms  a  dense  nodular  tumor  or  tumors,  which 
by  palpation  cannot  be  distinguished  from  carcinoma.  Jaundice  or 
ascites  may  develop  as  a  result  of  pressure  or  cicatricial  contraction. 
The  diagnosis  is  based  upon  the  history  of  syphilis  and  the  therapeutic 
test.  As  a  result  of  syphilitic  infiltration,  lobulation  may  occur  result- 
ing in  a  movable  mass  which  may  closely  simulate  floating  kidney 
except  for  its  shape  and  its  loose,  but  obvious,  connection  with  the 
liver. 


496  THE  ABDOMEN 

Tumors  of  the  gall-bladder  are  felt  just  below  the  costal  arch  at 
the  point  crossed  by  a  line  drawn  in  the  male  from  the  nipple  to  the 
umbilicus.  They  are  characterized,  in  the  absence  of  adhesions,  by  free 
mobility,  participation  in  the  respiratory  movements  of  the  liver,  and 
percussion  dulness  continuous  with  the  organ.  Colonic  inflation  pushes 
them  upward,  stomach  inflation  to  the  right.  Except  when  they  reach 
great  size,  they  are  neither  palpable  nor  rendered  markedly  more 
obvious  by  pressure  of  an  examining  hand  in  the  costovertebral  angle. 
In  distinguishing  such  tumors  from  those  originating  in  the  kidney  or 
the  suprarenal  body  this  failure  to  feel  the  mass  by  each  examining 
hand  in  bimanual  palpation  is  the  most  characteristic  feature.  Colonic 
inflation  will  demonstrate  the  postperitoneal  position  of  small  renal 
tumors. 

The  gall-bladder  tumor,  incident  to  overdistention  from  blocking  of  the 
cystic  (hydrops)  or  common  duct,  if  palpable,  forms  a  smooth  pyriform 
tumor,  usually  preceded  by  a  history  of  colic  in  the  former  case,  always 
accompanied  by  signs  of  jaundice  in  the  latter. 

The  tumor  of  acute  cholecystitis  is  usually  masked  by  the  accompany- 
ing tenderness  and  rigidity. 

The  tumor  of  malignant  disease  is  usually  preceded  by  a  history  of 
gallstone  colic.  If  palpable,  it  forms  a  nodular  mass  in  the  gall-bladder 
region,  and  should  be  diagnosticated  in  the  absence  of  disseminated  lesions 
by  exploratory  operation.  A  palpable  tumor  is  rarely  found  as  a  result 
of  the  chronic  cystitis  of  cholelithiasis,  except  as  the  result  of  omental 
adhesions. 

Renal  or  suprarenal  tumors  may  be  palpated  in  the  right  upper 
abdominal  quadrant,  but  usually  present  in  the  loin  between  the  costal 
border  and  iliac  crest.  They  are  made  more  obvious  in  front  by  deep 
pressure  in  the  costovertebral  angle,  exhibit  a  respiratory  excursion  less 
free  than  that  characteristic  of  the  swellings  of  the  liver,  and;  until  they 
have  reached  great  size,  can  be  demonstrated  as  postcolonic  by  inflation 
of  the  colon.  Moreover,  the  pain  and  tenderness  of  renal  swelling,  if 
these  be  present,  are  referred  to  the  costovertebral  angle  and  to  a  point 
on  the  anterior  belly  wall  directly  in  front  of  this,  and  the  pain  radiates 
downward  to  the  bladder,  external  genitals,  and  thighs. 

The  swelling  of  acute  infections  is  masked  by  the  local  tenderness  and 
rigidity  of  inflammation,  tumor  rarely  being  detected  until  the  perinephric 
tissues  are  involved.  The  urinary  findings  in  pyelonephritis  are  usually 
more  characteristic  than  is  swelling. 

Movable  or  floating  kidney  is  characterized  by  the  renal  conformation 
of  the  freely  movable  tumor,  ability  to  press  it  into  its  normal  position, 
accessibility  to  lumbar  palpation,  recurrence  of  the  displacement  on  deep 
breathing  or  coughing,  and  a  good  x-ray  picture. 

Hydronephrosis,  in  addition  to  forming  a  distinctly  lumbar  tumor, 
and  being  preceded  by  recurring  attacks  of  renal  colic,  commonly  exhibits 
fluctuation,  and  while  still  small  can  be  shown  to  be  postcolic.  Marked 
alterations  in  size  are  characteristic  of  intermittent  hydronephrosis. 

Neoplasms  of  the  kidney,  if  sufficiently  large  to  form  palpable  swell- 


ABDOMINAL  TUMORS  497 

ings,  are  usually  malignant;  sarcoma  in  children,  hypernephroma  or 
sarcoma  in  adults.  The  diagnosis  is  based  upon  rapid  growth,  lumbar 
projection,  postperitoneal  position,  and  blood  in  the  urine. 

Polycystic  disease  is  characterized  by  bilateral  nodular  renal  tumor 
and  the  urinary  findings  of  chronic  interstitial  nephritis. 

Tumors  of  the  suprarenal  bodies  (rare)  are  not  palpable  until  they  reach 
large  size;  their  diagnosis  as  such  is  dependent  upon  their  position,  the 
absence  of  blood  in  the  urine,  and,  possibly,  displacement  of  the  kidney. 
Orbital  metastases  are  noted  in  sarcoma. 

Swellings  of  the  Right  Lower  Abdominal  Quadrant. — ^These  may  be 
retroperitoneal  or  intraperitoneal.  If  movable  kidney  be  excepted  they 
are  fixed,  are  deeply  placed,  and  are  obscured  by  colonic  inflation. 

Congeniially  misplaced  kidney  forms  a  tumor  which  may  be  fixed  in 
its  abnormal  position.      Its  nature  may  be  suspected  from  its  shape. 

Movable  kidney  is  recognized  by  its  shape  and  freedom  of  excursion, 
particularly  in  the  direction  of  its  normal  site.  The  x-rays  will  be 
useful  in  demonstrating  the  absence  of  the  kidney  from  its  normal 
position. 

Aneurysm  of  the  external  iliac  artery  will  exhibit  the  characteristic 
features  of  this  affection  (see  p.  99). 

Glandidar  enlargement,  usually  malignant  and  secondary,  if  large 
enough  to  be  palpable,  is  suggested  by  the  presence  of  a  constitutional 
cause  or  a  primary  focus  and  a  nodular  mass  occupying  the  position  of 
the  lymphatic  chain. 

Iliac  Abscess. — ^Tuberculosis  of  the  sacro-iliac  articulation  or  of  the 
OS  innominatum  may  cause  first  an  infiltration,  later  an  abscess  beneath 
and  into  the  iliacus  muscle.  This  may  be  felt  by  palpation.  The  abscess 
usually  opens  externally  before  fluctuation  can  be  felt  through  the 
abdominal  walls.     The  a;-rays  are  helpful  in  framing  a  diagnosis. 

Psoas  abscess  forms  a  palpable  fluctuating  tumor  in  the  right  lower 
abdominal  quadrant  usually  long  before  it  presents  in  the  inguinal 
region  below  Poupart's  ligament.  The  symptoms  of  spinal  caries  are 
usually  pronounced. 

Perinephric  abscess  points  in  the  right  lower  quadrant.  The  tender- 
ness and  induration  may  be  followed  into  the  renal  region. 

Malignant  growth  from  the  pelvic  bones  or  deep  muscles  forms  a 
rapidly  growing  fixed  tumor  which  pushes  the  viscera  aside  and  which 
bimanual  examination  shows  is  not  attached  to  the  pelvic  organs. 

Intraperitoneal  Swellings  of  the  Right  Loiver  Quadrant. — These  are 
usually  due  to  inflammation  of  the  appendix,  to  cecal  carcinoma,  or  to 
tuberculosis  of  the  ileocecal  region.  Rare  causes  of  swelling  are  abscess 
secondary  to  gastric  or  duodenal  perforation  and  actinomycosis. 

The  tumor  of  appendicitis  is  usually  due  to  omental  adhesion  and 
thickening,  or  to  abscess  formation.  In  acute  cases  tenderness  and 
rigidity  obscure  the  tumor  and  are  the  dominant  symptoms. 

The  tumor  of  acute  cases  which  have  gone  on  to  abscess  formation 
is  usually  fixed  and  extremely  tender.     If  the  parietal  peritoneum  be 
uninvolved  and  the  abscess  be  limited  by  intestinal  coils,  tumor  with 
32 


498  THE  ABDOMEN 

slight  tenderness  may  be  the  only  symptom,  the  diagnosis  here  depend- 
ing upon  the  seat  of  the  tumor  and  its  fairly  rapid  (days,  weeks)  develop- 
ment, following  an  attack  of  acute  appendicitis.  In  the  absence  of  such 
a  history,  or  with  an  inflamed  appendix  lying  wide  of  its  normal  position, 
the  diagnosis  would  have  to  be  made  by  operation. 

Chronic  abscess  or  inflammatory  thickening  may  form  a  mass  in  the 
right  iliac  fossa  of  slow  growth  (months)  and  ultimately  large  size,  which 
may  so  closely  simulate  malignant  infiltration  as  to  require  operation 
for  a  differential  diagnosis.  Fever  is  more  likely  to  be  marked  in  the 
inflammatory  affection,  the  onset  is  usually  acutely  inflammatory,  there 
is  a  pronounced  polymorphonuclear  leukocytosis,  and  the  tumor  is  less 
sharply  defined  than  is  the  case  with  cancer. 

Malignant  growth  of  the  appendix  rarely  forms  a  palpable  tumor. 
The  distinction  from  chronic  appendicitis  should  be  made  by  opera- 
tion. 

Tuberculosis  of  the  cecum  forms  a  right  iliac  intra-abdominal  tumor, 
movable  or  fixed,  of  slow  growth  (years),  presenting  inflammatory  symp- 
toms of  moderate  severity,  and  attacking  by  preference  children  and 
young  adults.  The  hyperplastic  form  extends  along  the  ascending  colon, 
forming  a  sausage-shaped  tumor  without  mucous  membrane  ulceration, 
hence  there  is  no  blood  in  the  stools.  The  ulcerative  form,  usually 
secondary,  is  attended  with  parietal  involvement  and  fistula  formation. 
The  diagnosis  from  carcinoma,  at  a  time  when  this  is  serviceable,  can  be 
made  only  by  operation,  though  the  age  incidence  and  slow  progression 
are  suggestive  features. 

Carcinoma  of  the  cecum  forms  a  right  iliac  tumor,  movable  or  fixed, 
hard  and  nodular,  of  slow  growth  (months),  affecting  by  preference  the 
middle  aged  or  elderly,  usually  attended  with  ulceration  of  the  mucosa, 
hence  giving  blood  in  the  stools.  The  diagnosis  from  chronic  appendi- 
citis and  tuberculosis  should  be  made  by  incision. 

Actinomycosis  (rare)  forms  a  right  iliac  tumor  of  slow  growth  (months), 
which  involves  the  parietes,  opens  through  blind  fistulse,  and  is  distin- 
guished from  the  ulceration  found  in  tuberculosis  only  by  microscopic 
examination  of  the  discharge. 

Swellings  of  the  Left  Lower  Abdominal  Quadrant. — If  tumors  of  the  retro- 
peritoneal structure,  including  subacute  or  chronic  abscess,  glandular 
enlargements,  aneurysm,  and  displaced  or  enlarged  kidney,  be  excepted; 
likewise  those  tumors  incident  to  pathological  conditions  of  the  uterus, 
tubes,  and  ovaries  of  women,  or  the  bladder  in  either  sex,  swellings  of 
the  left  lower  abdominal  quadrant  are  usually  due  to  acute  intus- 
susception in  children,  cancer  or  acute  or  chronic  diverticulitis  of  the 
sigmoid  in  the  middle  aged  or  elderly,  either  of  these  conditions  or 
fecal  impaction  in  the  feeble  and  aged. 

Intussusception  is  marked  by  a  mass  which  is  movable,  often  freely 
so,  and  may  palpably  vary  in  size  as  a  result  of  peristaltic  contractions, 
is  sausage-shaped  and  attended  with  acute  or  subacute  symptoms  of 
intestinal  obstruction,  often  together  with  rectal  tenesmus  and  the 
passage  of  bloody  mucus. 


ABDOMINAL  TUMORS  499 

Cancer  may  be  unsuspected  until  a  tumor  is  felt.  This  is  likely  to  be 
nodular,  irregularly  rounded  in  shape,  and  more  superficial  and  movable 
than  a  retroperitoneal  growth.  Usually  detection  of  the  tumor  is  preceded 
by  persistent  deep-seated  pain  with  colicky  exacerbations  and  the  other 
symptoms  of  progressive  chronic  intestinal  obstruction.  There  is  likely 
to  be  occult  or  obvious  blood  in  the  stools. 

The  distinction  from  chronic  diverticulitis,  with  narrowing  of  the  lumen 
of  the  gut,  might  be  suggested  by  the  absence  of  occult  or  obvious  blood 
in  the  stools  in  the  latter  condition,  the  greater  tenderness,  the  more 
marked  blood  changes  of  infection,  and  the  younger  age  incidence. 
Usually  the  differential  diagnosis  must  be  an  operative  one,  at  times  a 
microscopic  one. 

Fecal  impaction  occurring  in  the  sigmoid  forms  a  mouldable,  freely 
movable  tumor,  the  diagnosis  of  which  must  often  depend  upon  the 
patient  and  skilful  use  of  laxatives  and  high  enemata.  Occult  or  even 
obvious  blood  in  the  stools  may  be  present  as  the  result  of  mechanical 
erosion.  Such  a  fecal  accumulation  may  be  the  result  of  intestinal 
angulation,  volvulus,  or  stenosis  from  inflammation  or  neoplasm. 

Intra-abdominal  Swellings  of  the  Left  Upper  Quadrant. — These  usually 
originate  in  the  kidney  or  suprarenal  body,  in  which  case  they  present 
in  the  loin  or  in  the  spleen.  In  the  latter  case  they  are  made  more 
obvious  by  colonic  inflation,  thus  differing  from  renal  tumor. 

Floating  spleen  may  have  a  range  of  motion  so  great  as  to  admit  of 
its  presence  in  any  part  of  the  abdomen.  It  is  usually  found  in  the  left' 
upper  quadrant,  or  at  least  can  be  more  readily  moved  in  this  direction 
than  in  any  other,  and  its  position  is  recognized  by  its  shape,  the  notch 
being  characteristic. 

The  general  symmetrical  enlargement  of  the  spleen  incident  to  malaria, 
typhoid,  miliary  tuberculosis,  Banti's  disease,  leukemia,  and  pseudo- 
leukemia is  attended  with  other  characteristic  symptoms. 

Abscess  of  the  spleen  may  be  so  latent  as  to  defy  diagnostic  efforts. 
Enlargement  of  the  spleen  occurring  in  the  course  of  rheumatic  fever, 
typhoid,  malaria,  or  other  infectious  process,  characterized  in  its  further 
development  by  chills,  fever,  sweat,  and  the  blood  changes  of  suppura- 
tion, and  particularly  by  pain,  tenderness,  and  fixation  of  the  diaphragm 
and  the  development  of  slight  basal  pleurisy,  should  suggest  splenic 
abscess. 

Echinococcus  cyst  forms  a  round,  usually  fluctuating  tumor  of  slow 
growth  (years)  and  not  prone  to  contract  adhesions  until  suppuration 
develops.  The  constitutional  symptoms  of  other  forms  of  splenic 
enlargement  are  absent.  Hydronephrosis  may  be  eliminated  by  colonic 
inflation,  examination  of  the  urine,  and  catheterization  of  the  ureters. 

Sarcoma  of  the  spleen  is  characterized  by  comparatively  rapid  (months) , 
somewhat  nodular,  painful  growth  of  the  organ  and  the  elimination  of 
constitutional  conditions  which  attend  other  forms  of  enlargement. 

Subphrenic  abscess  to  the  left  of  the  suspensory  ligament  of  the  liver 
is  usually  due  to  perforation  of  the  stomach,  pancreatitis,  splenic  abscess, 
perinephric  suppuration,  perforating  empyema,  or  necrosis  of  the  verte- 


500  THE  ABDOMEN 

brse  or  ribs.  Depending  on  the  primal  cause,  the  onset  will  be  stormy 
or  insidious.  In  its  developed  form  the  diaphragm  is  displaced  upward 
and  fixed.  The  spleen  and  stomach  are  pushed  down.  The  symptoms 
are  similar  to  subphrenic  suppuration  of  the  right  side. 

Tumors,  when  they  are  not  observed  until  they  reach  large  size,  may 
so  fill  the  abdominal  cavity  that  their  point  of  origin  may  be  difiicult  to 
determine  except  by  operation. 

Certain  acute  conditions  are  attended  with  tumor  formation  which  may 
vary  in  its  location.  The  rapid  distention  of  the  sigmoid  incident  to 
volvulus  may  force  this  loop  of  gut,  normally  pelvic  in  position,  as  high 
as  the  lower  border  of  the  stomach.  Internal  strangulation  or  incar- 
ceration by  twist  or  band,  depending  on  its  seat,  may  be  characterized 
by  the  rapid  development  of  a  resonant  tumor  in  any  part  of  the  belly. 
The  same  may  be  said  of  acute  obstruction  incident  to  enteroliths,  foreign 
bodies,  masses  of  round-worms,  large  gallstones  which  have  ulcerated 
into  the  gut,  malignant  growths  of  the  small  intestine,  hematoma,  torsion 
or  infection  of  the  omentum,  disseminated  carcinoma  or  tuberculosis 
of  the  peritoneum.  The  abscess  due  to  appendicitis  may  be  wide  of 
its  usual  seat. 

HERNIA. 

Hernia,  as  the  term  is  generally  used,  implies  the  protrusion  of  an 
abdominal  organ  through  a  parietal  opening.  The  affection  is  com- 
monest in  infancy,  old  age,  and  puberty. 

The  usual  predisposing  causes  are  congenital  malformation,  a  flabby 
musculature,  and  looseness  of  cellular  tissue,  often  incident  to  emacia- 
tion. The  pull  of  a  subserous  lipoma,  the  recurring  push  of  a  chronic 
cough,  repeated  straining  incident  to  obstructed  urination  or  defecation, 
the  intra-abdominal  pressure  of  violent  muscular  effort,  trauma — these 
are  the  common  exciting  causes. 

Diagnostic  symptoms  of  hernia  are:  The  presence  of  a  tumor,  usually 
in  a  hernial  region,  or  in  one  weakened  by  traumatism,  generally  of 
gradual  formation  (weeks,  months),  at  times  developed  suddenly, 
unattended  with  inflammatory  symptoms,  varying  in  size  and  consistency 
in  accordance  with  the  position  of  the  patient  and  changes  in  intra- 
abdominal tension,  giving  expansile  impulse  on  coughing,  usually 
resonant  on  percussion,  reducible,  often  with  a  gurgling  sound,  and 
readily  retained  by  moderate  pressure  over  its  orifice  of  escape.  The 
examining  finger  can  be  pushed  deeply  into  this  orifice. 

An  omental  hernia  will  exhibit  neither  resonance  on  percussion  nor 
gurgling  on  manipulation  and  reduction,  and,  if  irreducible,  may  not 
obviously  change  in  size  or  conformation  with  changes  in  the  patient's 
position,  nor  give  an  expansile  impulse  on  coughing.  The  neck  of  such 
a  tumor  can,  however,  usually  be  traced  through  the  hernial  orifice 
and  canal  into  the  interior  of  the  abdomen,  and  there  can  be  obtained 
a  history  of  its  gradual  development  and  of  its  repeated  spontaneous 
or  manual  reduction  in  its  early  course. 


HERNIA  501 

Internal  hernise  into  the  jejunoduodenal,  pericecal,  and  sigmoid 
fossoe,  or  through  the  foramen  of  Winslow,  can  be  diagnosticated  only  by 
operation  called  for  by  the  complication  of  incarceration  or  strangulation. 

The  external  hernise  are  readily  recognized  if  present  at  the  time  of 
examination,  except  in  the  case  of  small  protrusions  occurring  in  fat 
people.  The  patient  may,  however,  give  a  history  quite  typical  of  hernia, 
yet  fail  to  exhibit  the  lesion.  Enlargement  of  the  ring  usually  can  be 
demonstrated.  Protrusion  may  be  accomplished  by  violent  coughing,  by 
lifting  a  heavy  weight  with  the  knees  straight  and  the  back  bent  for- 
ward, or  by  seating  the  patient  on  the  edge  of  a  chair  with  flexed  knees 
and  the  legs  moderately  separated  and  directing  him  to  make  straining 
efforts  as  in  defecation. 

The  bulging  of  the  abdominal  wall  over  Poupart's  ligament  is  a 
natural  conformation  in  many  men,  nor  is  impulse  against  the  finger 
passed  through  the  patulous  external  ring  of  absolutely  diagnostic 
moment,  in  so  far  as  the  presence  of  a  hernia  which  is  likely  to  be  pro- 
gressive is  concerned. 

A  hernia  is  termed  irreducible  when  it  remains  permanently  in  its  sac. 
This  is  usually  due  to  adhesions  between  the  hernia  and  the  sac  wall. 

Incarcerated  hernia  is  one  in  which  there  is  obstruction  to  the  onward 
passage  of  the  intestinal  contents  from  massing  of  feces  incident  to 
angulation  or  sharp  flexion  of  the  gut,  or  the  pressure  of  the  hernial 
ring.  The  circulation  of  the  involved  bowel  loops  is  not  obstructed. 
The  symptoms  are  those  of  an  irreducible  hernia  larger  than  usual 
and  accompanied  by  colicky  pain,  active  peristalsis,  vomiting,  and  con- 
stipation, with  remissions  or  intermissions  and  exacerbation.  There 
may  be  local  tenderness,  but  inflammatory  symptoms  are  absent. 

A  strangulated  hernia  is  one  in  which  there  is  blood  stasis  from  con- 
striction. This  constriction,  which  may  lie  in  the  ring  or  in  the  sac 
at  its  neck,  may  become  suddenly  operative  by  an  added  loop  of  gut 
or  portion  of  omentum  being  suddenly  thrust  through  it. 

Strangulation  is  attended  at  times  with  shock,  usually  by  severe  pain 
exhibiting  paroxysmal  exacerbations,  vomiting,  constipation,  and,  follow- 
ing this,  the  hyperperistalsis  of  acute  obstruction.  The  hernia  itself  is 
painful,  tender,  and  swollen.  There  is  no  impulse  on  coughing,  and  a 
preceding  resonance  may  be  exchanged  for  percussion  dulness  incident 
to  efl^usion  into  the  sac. 

Strangulation  occurring  in  long-standing  irreducible  hernise,  par- 
ticularly those  of  the  aged,  may  be  marked  at  first  by  no  symptoms 
other  than  colicky  pains,  moderate  vomiting,  constipation,  and  a  slight 
increase  in  tenderness.  In  these  cases  the  rapid  development  of  pro- 
found toxemia  may  be  the  most  conspicuous  symptom.  Under  such 
circumstances,  when  there  is  a  double  hernia,  a  not  unusual  condition 
in  the  aged,  the  determination  as  to  which  one  is  responsible  for  symp- 
toms may  be  impossible  without  operation. 

When  strangulation  is  due  to  bands  or  adhesions  within  the  sac,  the 
reduction  of  the  hernia  will  not  be  followed  by  relief  of  symptoms. 

The  severe   abdominal  pain  of  uremia,  with  vomiting  and  consti- 


502 


THE  ABDOMEN 


pation,  if  associated  with  hernia,  may  cause  error  in  treatment,  nor  is 
an  examination  of  urine  helpful,  except  in  that  it  may  show  chronic 
nephritis.  If,  with  such  symptoms,  local  tenderness  and  increased  size 
were  present  in  an  irreducible  hernia,  the  diagnosis  would  have  to  be 
made  by  operation. 

The  distinction  between  strangulation  and  incarceration,  or  simple 
inflammation,  when  this  is  not  clear,  should  be  made  by  timely  opera- 
tion. 

Inguinal  Hernia. — This,  the  commonest  form  of  hernia,  may  be  in- 
complete or  complete,  congenital  or  acquired,  and  is  most  frequent  in 
males. 

Fig.  336 


Large  bilateral  inguinoscrotal  hernia.  Incompletely  reducible;  penis  concealed  by  downward 
dislocation  of  skin.  Preputial  orifice  at  middle  of  swelling.  All  characteristic  signs  of  hernia 
present.      (Camett.) 


Indirect,  or  oblique,  inguinal  hernia  passes  primarily  through  the 
internal  ring,  with  the  deep  epigastric  artery  necessarily  internal  to 
the  neck  of  its  sac.  It  usually  contains  the  ileum  and  omentum,  not 
infrequently  the  cecum  or  appendix,  or  both,  on  the  right  side,  or 
the  colon  on  the  left  side,  in  which  cases  the  sac  may  be  incomplete 
(sliding  hernia). 

At  times,  especially  in  hernise  which  have  recurred  after  radical 
cure,  the  bladder  forms  a  part  of  the  hernial  projection,  usually  with- 
out a  peritoneal  investure,  and  may  be  wounded  during  operation.  Its 
presence  is  suggested  by  a  mass  of  fat  pulled  into  the  wound  at  its 
lower  angle. 


HERNIA 


503 


When  a  considerable  portion  of  the  bladder  is  included  in  the  hernia 
and  the  portion  communicates  freely  with  the  rest  of  the  bladder  cavity, 
there  will  be  a  diminution  in  the  size  of  the  tumor  after  urination; 
or,  if  this  is  not  the  case,  after  having  urinated,  and  having  emptied 
the  sac  by  manipulation,  a  further  considerable  quantity  of  urine  can 
be  passed. 

There  is  usually  an  associated  cystitis,  and  the  hernia  can  be  made 
more  prominent  by  filling  the  bladder  with  an  injection. 

The  indirect  or  oblique  hernia  is  usually  dependent  for  its  develop- 
ment upon  a  persistent  patulous  condition  of  the  peritoneal  pouch  which 
accompanies  the  testicle  in  its  descent.  When  this  pouch  remains 
completely  open,  and  the  hernial  contents  pass  down  to  the  testicle, 
the  hernia  is  called  congenital.     When  the  pouch  is  closed  just  above 


Fig.  337 


Oblique  inguinal  hernia,  showing  fulness  along  inguinal  canal  and  at  external  ring,  but  not 
extending  into  the  scrotum. 

the  testicle,  the  hernia  descending  with  the  cord,  it  is  called  funicular. 
When  the  pouch  remains  open  excepting  at  the  internal  ring,  either 
an  infantile  or  encysted  hernia  may  develop.  In  the  former  case  a 
sac  forms  behind  the  patulous  funicular  process;  in  the  latter,  a  sac 
becomes  invaginated  into  its  lumen. 

The  hernial  sac  incident  to  a  patulous  condition  of  the  vaginal  tunic 
not  infrequently  exhibits  constrictions,  valve-like  folds,  and  diverticula, 
which  may  be  even  larger  than  the  direct  sac.  These  diverticulfe  may 
pass  between  any  of  the  abdominal  layers,  and  may  mislead  the  surgeon 
into  the  belief  that  he  has  accomplished  a  reduction  of  the  hernia  when 


504  THE  ABDOMEN 

in  reality  he  has  pressed  it  into  a  side  pocket.  The  hernia  can  be  made 
to  alternate  between  its  two  positions.  A  properitoneal  hernia  is  one 
which  habitually  lodges  in  an  intraparietal  peritoneal  diverticulum. 
•  Direct,  or  internal,  inguinal  hernia  passes  to  the  inner  side  of  the 
deep  epigastric  artery  between  it  and  the  outer  border  of  the  rectus 
muscle.  It  is  always  acquired,  of  slow  formation,  occurs  in  elderly 
males,  and  is  due  to  muscular  and  fibrous  relaxation. 

The  sac  of  the  indirect  or  oblique  inguinal  hernia  passes  downward 
and  inward,  then  forward.  The  direct  hernia  comes  directly  forward. 
From  long-continued  drag,  an  oblique  inguinal  hernia  may  seem 
direct.  The  position  of  the  deep  epigastric  artery  in  relation  to  the 
sac,  if  it  can  be  felt,  which  is  exceptional,  will  establish  the  distinction. 
The  hernise  of  the  young  and  vigorous  are  practically  always  oblique. 
The  hernise  of  the  old  and  debilitated  are  often  direct  and  bilateral. 

When  an  inguinal  hernia  is  incomplete,  it  must  be  distinguished  in 
infants  from  retained  testicle.  Absence  of  this  gland  from  its  usual 
position  would  seem  a  suggestive  feature,  but  is  often  overlooked.  The 
testicle  can  be  distinctly  outlined,  and  never  exhibits  an  expansile  im- 
pulse on  coughing.  The  two  conditions  of  non-descent  and  hernia  are 
often  associated. 

Hydrocele  of  the  cord,  common  in  infants,  exhibits  a  high  degree  of 
translucency  and  fluctuation.  It  may  traverse  the  entire  length  of  the 
inguinal  canal,  and  in  rare  cases  may  be  completely  reducible;  this 
is  accomplished  very  slowly,  nor  is  there  sudden  return  of  the  complete 
swelling,  as  is  the  case  in  hernia.  It  is  always  dull  on  percussion  and 
does  not  exhibit  expansile  impulse  on  coughing.  A  slight  translucence 
is  sometimes  observed  in  the  hernias  of  infants.  Cyst  of  the  canal  of 
Nuck,  occurring  in  women,  rarely  offers  diagnostic  difficulties. 

The  distinction  between  an  irreducible  omental  hernia  and  a  liporna 
of  the  cord  may  be  extremely  difficult.  The  possibility  of  tracing  the 
neck  of  the  hernia  into  the  abdominal  cavity  through  its  aperture  of 
escape  would  be  suggestive  of  hernia.  Pronounced  movement  imparted 
by  traction  upon  the  testicle  would  be  more  characteristic  of  lipoma  of 
the  cord. 

Hematocele  exhibits  the  characteristics  of  hydrocele,  except  that  it 
is  less  soft  and  fluctuating  and  gives  no  translucence  to  light. 

Dermoid  of  the  inguinal  canal  (rare)  exhibits  a  distinct  outline,  and 
except  for  its  position  has  none  of  the  characteristics  of  hernia. 

Postperitoneal  abscess  commonly  points  below  Poupart's  ligament. 
The  symptoms  of  the  cause  underlying  this  condition  are  usually  suffi- 
ciently obvious.  Unless  it  be  acute  or  subacute,  the  swelling  can  be 
traced  to  the  inguinal  fossa  and  is  attached  to  the  deeper  structures. 

An  inflamed  inguinal  gland,  if  complicated  by  hernia,  may  occasion 
some  diagnostic  difficulty,  since  by  its  extension  it  may  occasion  inflam- 
mation of  the  sac,  deep  pain,  nausea,  vomiting,  and  constipation.  Diag- 
nosis in  the  presence  of  obstructive  symptoms  should  be  made  by 
operation. 


HERNIA  505 

Femoral  Hernia. — Femoral  hernia,  protruding  through  the  femoral 
ring  and  canal  and  the  saphenous  opening,  never  attains  the  huge 
size  noted  in  inguinal  hernia.  It  is  always  acquired,  and  is  commonest 
in  adult  females.  It  appears  as  a  globular  swelling  below  the  inner 
third  of  Poupart's  ligament,  and  often  turns  upward,  thus  simulating 
inguinal  hernia.  Its  neck  lies  below  Poupart's  ligament  and  external 
to  the  spine  of  the  pubis,  while  the  neck  of  an  inguinal  hernia  is  above 
Poupart's  ligament  and  internal  to  the  pubic  spine.  This  bony  point 
is  located  by  abducting  the  thigh  and  following  upward  the  adductor 
longus  tendon  which  is  attached  just  below  it. 

The  distinction  between  irreducible  femoral  epiplocele  and  lipoma 
may  be  impossible  unless  there  be  given  a  clear  history  of  the  gradual 
formation  of  a  tumor  at  one  time  distinctly  reducible,  or  the  lipoma 
exhibit  its  characteristic  lobulations,  skin  adhesions,  and  free  mobility 
on  the  deeper  parts.  In  case  of  doubt  the  diagnosis  should  be  made 
by  operation. 

The  distinction  between  femoral  hernia  and  psoas  abscess  or  cold 
abscess  from  necrosis  of  the  pelvic  bones  is  based  in  part  upon  the 
usual  seat  of  the  two  affections.  The  hernia  lies  to  the  inner  side  of  the 
femoral  artery,  the  abscess  points  to  the  outer  side.  The  psoas  abscess 
usually  can  be  traced  through  the  abdominal  parietes,  passing  upward 
along  the  psoas  muscle  or  backward  and  outward  into  the  iliac  fossa, 
and  fluctuation  can  be  elicited  in  it  by  abdominal  pressure.  It  may 
exhibit  both  partial  reducibility  and  expansile  impulse  on  coughing. 

Cyst  in  the  region  of  the  femoral  hernia,  due  possibly  to  obliteration 
of  the  abdominal  opening  of  a  femoral  sac,  is  suggested  by  fluctuation 
if  this  can  be  clearly  elicited.  It  often  exhibits  the  consistency  of  an 
epiplocele  and  should  be  distinguished  from  the  latter  condition  by 
operation. 

The  distinction  from  inflamed  glands  is  based  upon  the  presence  of 
an  adequate  cause  for  this  condition,  the  rapid  development,  induration 
and  tenderness,  and  the  early  appearance  of  the  skin  phenomena  of 
inflammation  in  the  absence  of  any  marked  gastro-intestinal  disturbance. 

Lymphangiectasis  or  venous  varicosities  may  form  a  tumor  in  the 
femoral  region  markedly  influenced  in  size  by  position  and  abdominal 
tension,  and  in  the  case  of  the  veins,  giving  expansile  impulse  on  cough- 
ing. The  convolutions  of  the  dilated  vessels  are  usually  distinctly 
seen,  if  not  at  the  seat  of  maximum  swelling,  at  least  below,  nor  does 
diagnosis  present  difflculties  if  the  possibility  of  tumor  formation  from 
these  sources  be  borne  in  mind. 

Umbilical  Hernia. — Umbilical  hernia  is  a  protrusion  of  one  or  more 
abdominal  structures  at  the  umbilicus.  The  congenital  form  is  due 
to  imperfect  union  of  the  two  lateral  plates  of  the  abdomen  at  the  mid- 
line; the  protrusion  occurs  into  the  base  of  the  cord,  and  the  contents 
are  visible  through  the  amniotic  layer  which  covers  them. 

Acquired  umbilical  hernia  occurs  either  in  early  infancy  or  in  women 
after  their  twenty-fifth  year.  Repeated  pregnancy  and  obesity  are 
favoring  factors.     The  upper  and  weaker  part  of  the  navel  is  the  seat 


506 


THE  ABDOMEN 


of  predilection.  The  umbilical  hernia  quickly  becomes  irreducible, 
attains  huge  size,  and  is  subject  to  strangulation.  The  diagnosis  is 
obvious. 

Fig.  338 


Umbilical  hernia. 


Type  commonly  seen  in  infants.     Easily  reducible. 
Ring  tight  to  tip  of  finger. 


Impulse  on  coughing. 


Ventral  Hernia. — ^Ventral  hernia  may  occur  through  any  part  of  the 
abdominal  wall  weakened  by  scar,  muscular  or  fascial  rupture,  or  dias- 
tasis. That  form  due  to  separation  of  the  recti  muscles  is  best  demon- 
strated by  directing  the  patient  to  lie  on  her  back  and  raise  her  head 
and  shoulders  from  the  pillow  without  the  aid  of  the  arms;  the  hernial 
protrusion  can  then  be  seen  and  the  median  borders  of  the  recti  muscles 
can  be  felt. 

Lumbar  Hernia. — Lumbar  hernia,  if  not  due  to  scar,  usually  occurs 
through  Petit's  triangle,  a  weak  space  lying  between  the  external 
oblique  and  latissimus  dorsi  muscles,  slightly  behind  the  summit  of  the 
iliac  crest,  or  through  a  vascular  opening  on  the  latissimus  slightly 
behind  this. 

The  lumbar  region  is  a  favorite  seat  for  both  abscess  and  lipoma. 
The  former  may  be  reducible  and  give  impulse  on  coughing,  but 
exhibits  characteristic  symptoms  of  the  causative  lesion.  The  latter 
is  usually  lacking  in  hernial  symptoms. 

Sciatic,  or  Ischiatic,  Hernia. — Sciatic,  or  ischiatic,  hernia  occurs  through 
the  greater  or  lesser  sacrosciatic  foramen  and  may  be  either  above  or 
below  the  pyriformis  muscle.  It  may  remain  under  the  gluteus  maximus 
muscle  or  protrude  beneath  its  lower  border. 

Obturator  Hernia. — Obturator  hernia  (rare)  is  not  likely  to  be  recog- 
nized except  when  symptoms  of  strangulation  call,  as  they  invariably 
do,  for  a  careful  examination  of  the  hernial  orifices.  Under  such  cir- 
cumstances there  may  be  felt  a  tender  tumor  in  the  region  of  the  pecti- 


THE  STOMACH  AND  DUODENUM  507 

neus  muscle.  As  a  means  of  lessening  tension,  the  thigh  of  the  affected 
side  will  be  kept  flexed,  nor  can  it  be  moved  without  pain.  More- 
over, there  will  probably  be  pain  referred  along  the  course  of  the  obtura- 
tor nerve  and  disturbance  of  sensation  on  the  inner  surface  of  the  thigh 
and  leg. 

The  obturator  hernia  lies  below  and  internal  to  the  position  of  femoral 
hernia. 

Perineal  Hernia. — Perineal  hernia  protrudes  through  some  part  of 
the  pelvic  floor,  usually  between  the  fibers  of  the  levator  ani  muscle,  or 
between  it  and  the  coccygeus.  It  may  lie  beside  the  rectum  or  the 
vagina,  bulging  into  their  lumina,  or  appear  in  the  labium  majus,  form- 
ing a  vulvar  hernia.  Since  the  sac  invariably  contains  gut,  the  tumor 
is  readily  reducible,  and  exhibits  practically  all  of  the  characteristic 
hernial  features;  a  diagnostic  failure  is  scarcely  possible  if  the  existence 
of  hernia  in  this  region  be  recognized. 

Little's  Hernia. — ^This  is  one  made  up  of  a  Meckel's  diverticulum. 

Richter's  Hernia. — This  is  one  in  which  only  a  portion  of  the  circum- 
ference of  a  knuckle  of  intestine  is  involved. 

Strangulation  of  either  of  these  two  hernise  should  give  mild  symp- 
toms.    The  diagnosis  should  be  made  by  operation. 

Internal  Hemige. — The  duodenojejunal,  pericecal,  intersigmoid,  and 
foramen  of  Winslow  hernise  can  be  diagnosticated  as  such  only  when, 
because  of  symptoms  of  internal  strangulation,  operation  is  required. 

Diaphragmatic  hernia,  usually  following  a  wound  of  the  diaphragm, 
either  immediately  or  long  after,  is  characterized  by  the  acute  onset  of 
dyspnea,  shock,  and  the  symptoms  of  intense  strangulation,  with  the 
tympany  of  an  abdominal  organ  elicited  by  chest  examination,  and 
displacement  of  the  left  lung  and  the  heart.  If  of  gradual  formation 
incident  to  congenital  malformation,  intestinal  gurgling  heard  on  chest 
auscultation  may  suggest  the  diagnosis.  Displacement  of  the. heart  to 
the  right  in  the  absence  of  pleural  effusion  is  suggestive.  Diagnosis  is 
usually  not  made  until  the  symptoms  of  internal  strangulation  call  for 
operation. 

THE  STOMACH  AND  DUODENUM. 

From  the  subdiaphragmatic  portion  of  the  esophagus  the  empty 
stomach  hangs  as  a  flaccid  sac,  the  long  axis  of  which,  at  first  vertical, 
swings  forward  and  to  the  right  until  the  pylorus  is  reached. 

When  distended,  the  stomach  assumes  a  pyriform  shape,  the  larger 
expansion,  or  fundus,  extending  to  the  left  and  rising  posteriorly  one  to 
two  and  one-half  inches  above  the  level  of  the  cardia,  thus  lying  behind 
the  apex  of  the  heart.  The  greater  curvature  of  the  full  stomach  is 
usually  one  or  two  inches  above  the  level  of  the  umbilicus. 

The  cardia,  which  is  the  most  fixed  part  of  the  stomach,  is  placed  at 
a  depth  of  about  five  inches,  directly  behind  the  sternal  articulation  of 
the  left  seventh  costal  cartilage.  The  extremely  movable  pylorus  lies, 
when  the  stomach  is  empty,  an  inch  below  and  the  same  distance  to 


508  THE  ABDOMEN 

the  right  of  the  tip  of  the  ensiform  cartilage,  on  a  level  with  the  body 
of  the  eleventh  or  twelfth  dorsal  vertebra. 

The  capacity  of  the  stomach  at  birth  is  from  20  to  30  c.c.  This  rapidly 
increases  until  at  the  end  of  the  third  month  it  is  about  100  c.c.  There- 
after, for  a  period  of  three  months,  there  is  very  little  increase  in  size. 
Then  follows  a  capacity  development  commensurate  with  the  general 
body  growth.  The  adult  stomach  holds  from  1500  to  2000  c.c,  but 
these  figures  by  no  means  represent  the  extremes  of  normal  variation. 
Moreover,  the  position  of  this  organ  and  the  direction  of  its  long  axis 
may  depart  greatly  from  that  just  given,  without  other  signs  or  symp- 
toms of  impaired  function. 

The  larger  bulk  of  the  stomach,  lying  to  the  left  of  a  line  dropped 
in  the  long  axis  of  the  body  from  the  right  side  of  the  cardiac  orifice, 
and  including  the  fundus,  the  body,  and  a  large  part  of  the  greater 
curvature  nearly  to  the  antrum  pylori,  is  mainly  a  secreting  reservoir 
and  a  mixing  chamber  for  the  conversion  of  food  into  chyme.  Its  few 
collecting  lymph  glands  communicate  with  the  splenic  group.  It  is  this 
portion  of  the  stomach  which  is  principally  affected  by  dilatation. 

The  thicker  and  more  muscular  pyloric  end  of  the  stomach  lies  to  the 
right  of  the  vertical  line  just  given,  and  is  not  only  a  secreting  but  an 
actively  moving  part  which  accomplishes  the  thorough  mixing  of  the  food 
with  the  gastric  juices  and  propels  this  when  it  is  properly  prepared 
through  the  pylorus  into  the  duodenum.  Collecting  lymph  glands  are 
abundant  about  this  portion  of  the  stomach,  particularly  along  its 
lesser  curvature,  the  direction  of  the  lymph  flow,  even  from  the  lower 
border  of  the  antrum,  being  toward  this  group. 

This  portion  of  the  stomach  is  mainly  affected  by  ulcer  and  cancer  and 
perigastric  adhesions. 

The  stomach  is  essentially  a  secreting  and  not  an  absorbing  organ. 
Its  secretion,  hydrochloric  acid,  propepsin,  and  lab  ferment,  is  actively 
excited  by  psychical  influences,  but  is  in  the  main  under  the  direct 
control  of  its  essential  ganglia.  This  is  also  true  of  its  movements.  Its 
function  is  that  of  proteid  digestion,  particularly  of  connective  tissue, 
thus  facilitating  the  later  action  of  the  pancreatic  secretion  upon  the 
fats  and  muscle  cells.  Its  secretion  has  a  distinctly  antiseptic  action 
upon  food. 

The  cardia  is  a  physiologically  incompetent  valve  in  infancy.  In 
adults  it  is  occasionally  subject  to  spasm.  It  admits  from  the  stomach 
side  three  fingers  to  the  first  joint.  The  pylorus,  occasionally  subject 
to  spasm  and  hypertrophy  in  infancy,  a  frequent  seat  of  ulceration  in  the 
adult,  should  normally  admit  the  index  finger  past  the  first  joint.  It  has 
a  free  range  of  motion,  and,  unless  distinctly  indurated,  is  not  palpable. 

The  normal  stomach  should  have  disposed  of  an  ordinary  full  meal  in 
six  hours,  vomiting  efforts  or  expressage  showing  no  remains  of  such  a 
meal  after  this  interval.  The  test  breakfast  of  tea  and  toast  is  often 
passed  from  the  stomach  in  one  hour.  Persistent  delay  in  transmission 
indicates  either  a  deficient  propulsive  power  or  obstruction,  usually  the 
latter. 


.THE  STOMACH  AND  DUODENUM  509 

The  cardinal  symptoms  of  surgical  affections  of  the  stomach  are 
pain,  evidences  of  pyloric  obstruction,  hemorrhage,  and  tumor. 

Pain,  which  in  its  time  of  onset  and  maximum  severity  bears  a  relation 
to  food  ingestion,  which  is  sharply  localized  and  which  is  relieved  by 
vomiting,  is  a  symptom  to  which  great  importance  is  justly  attached, 
particularly  when  it  is  associated  with  an  area  of  tenderness  to  deep 
palpation,  and,  exceptionally,  with  a  sharply  localized  area  of  parietal 
hyperalgesia. 

Hemorrhage,  as  shown  by  examination  of  the  vomitus,  or  of  the  matter 
expressed  from  the  stomach,  or  of  the  stools,  is  of  diagnostic  value  in 
accordance  with  its  severity,  recurrence,  persistence,  and  its  association 
with  other  symptoms. 

Pyloric  obstruction  is  characterized  by  delay  in  the  passage  of  the 
stomach  contents,  hypertrophy,  visible  peristalsis  in  thin  persons, 
gurgling  sounds,  eructations  and  postprandial  discomfort,  and,  in  the 
late  stages,  gastric  dilatation  and  vomiting  of  food  taken  many  hours 
before,  and  exceptionally  tetany. 

Either  absence  or  excess  of  hydrochloric  acid  or  of  the  digestive 
ferments  constitutes  a  corroborative  rather  than  a  pathognomonic  sign 
of  surgical  disease.  The  bacteria  and  ferments  of  decomposition  are 
indicative  of  obstruction,  and  depend  upon  its  degree  rather  than  upon 
its  nature. 

Tumor,  a  late  manifestation  of  gastric  disease  if  congenital  hyper- 
trophic stenosis  be  excepted,  is  usually  perceptible  to  palpation  only 
when  it  involves  the  pylorus  or  the  anterior  stomach  wall.  Extensive 
infiltration  of  the  posterior  wall  can  be  felt  when  the  stomach  is  not 
distended. 

The  duodenum,  the  thickest-walled,  widest,  and  most  vascular  part  of 
the  small  intestine,  ten  to  twelve  inches  long,  and  forming  in  its  course 
a  V  or  U,  within  the  angle  or  concavity  of  which  lies  the  head  of  the 
pancreas,  is  movable  and  provided  with  a  complete  peritoneal  invest- 
ment only  for  the  first  two  inches  of  its  course.  The  direction  of  this 
movable  part  is  transverse,  with  an  upward  and  backward  tilt,  its  distal 
end  forming  the  lower  border  of  the  foramen  of  Winslow,  while  behind  it 
lie  the  common  bile  duct,  the  hepatic  artery,  and  the  portal  vein.  Below 
is  placed  the  head  of  the  pancreas. 

The  rest  of  the  duodenum  is  covered  with  peritoneum  only  in  front. 
The  descending  portion,  about  three  inches  in  length,  lies  to  the  right 
of  the  head  of  the  pancreas,  with  the  common  bile  duct  passing  behind  it 
and  entering  1.4  inches  below  a  crescentic  fold  of  mucous  membrane 
placed  at  the  junction  of  the  first  and  second  parts  of  the  duodenum  on 
the  posterior  aspect.  At  the  point  of  entrance  there  is  a  papilla  which 
caps  the  ampulla  of  Vater,  a  space  lying  within  the  wall  of  the  bowel 
and  receiving  both  the  biliary  and  the  pancreatic  duct.  These  ducts 
may  enter  by  separate  orifices.  The  accessory  pancreatic  duct  (duct  of 
Wirsung)  enters  the  duodenum  above  the  papilla. 

The  longest  portion  of  the  duodenum,  the  third,  or  transverse  (five 
inches),  passes  below  the  pancreas  across  the  great  vessels  from  right  to 


510  '  TEE  ABDOMEN.  , 

left  and  slightly  upward,  behind  the  superior  mesenteric  vessels  and 
the  root  of  the  mesentery.  The  ascending  fourth  part  lies  almost  as 
high  as  the  beginning  of  the  duodenum,  on  a  level  with  the  first  or 
second  lumbar  vertebra,  and  is  sharply  angled  forward  at  its  continua- 
tion with  the  jejunum,  being  held  in  position  by  a  musculofibrous  band 
— the  ligament  of  Trietz — which,  in  conjunction  with  the  peritoneal  fold 
passing  from  the  duodenum  to  the  right  parietal  peritoneum,  forms  the 
duodenojejunal  fossa,  into  which  retroperitoneal  hernia  may  occur. 

As  is  the  case  with  the  stomach,  the  duodenum  is  essentially  a  secre- 
ting and  not  an  absorbing  organ.  Under  the  stimulating  effect  of  the 
acid  chyme  of  the  stomach  it  forms  a  product,  secretin,  which  not  only 
excites  its  own  cellular  activity  but  stirs  the  liver  and  pancreas  to  hyper- 
secretion. The  duodenal  secretion  also  contains  invertin  which  splits 
cane  sugar,  lactase  which  acts  on  lactose  and,  of  major  importance, 
entero kinase  which  converts  the  trypsinogen  into  trypsin,  thus  activating 
the  pancreatic  secretion. 

Just  below  the  entrance  of  the  bile  and  pancreatic  ducts  there  has  been 
described  a  sphincteric  arrangement  of  fibers  (Ochsner),  the  presence 
of  which  there  is  clinical  evidence  to  support.  The  invariable  or  usual 
presence  of  such  a  sphincter,  however,  has  not  been  confirmed  anatom- 
ically (Boothby). 

The  crossing  of  the  superior  mesenteric  vessels  and  root  of  the  mesen- 
tery over  the  third,  or  transverse,  portion  of  the  duodenum  has  been  con- 
sidered the  etiological  basis  of  some  cases  of  acute  gastric  dilatation. 

The  lymphatic  glands  of  the  duodenum,  few  in  nmnber,  lie  along  its 
inner  angle  or  curve,  their  vessels  passing  to  the  glands  along  the  lesser 
curvature  of  the  stomach. 

The  symptoms  of  surgical  affections  of  the  duodenum  are  pain,  tender- 
ness, hemorrhage,  obstruction  to  the  onward  passage  of  chyme  from  the 
stomach,  or  bile  or  pancreatic  juice  from  their  secreting  glands,  and  very 
exceptionally,  palpable  tumors.  The  pain  has  a  constant  and  distinct 
relation  to  gastric  function,  coming  on  some  time  (hours)  after  eating 
and  being  temporarily  relieved  by  taking  food.  The  pain  and  associ- 
ated tenderness  on  deep  palpation  are  often  placed  to  the  left  of  the  tip 
of  the  ensiform  and  somewhat  below  it.  The  hemorrhage  may  appear 
only  in  the  stools. 

Trauma  of  the  Stomach. — Contusion. — Contusion  is  characterized 
by  shock,  vomiting,  sometimes  of  blood,  severe  pain  and  very  often 
localized  tenderness  and  rigidity.  There  may  be  free  bleeding  either 
into  the  stomach  itself  or  into  the  peritoneal  cavity  without  actual  rup- 
ture of  all  the  gastric  coats. 

The  diagnosis  from  rupture  is  based  upon  prompt  recovery  from  shock 
and  the  retrogression  of  symptoms. 

Rupture  of  the  Stomach. — Rupture  of  the  stomach  is  usually  due  to 
external  violence,  exceptionally  in  surfeited  drunkards  to  muscular 
action.  It  is  characterized  by  severe  pain,  shock,  and  the  rapid  devel- 
opment of  symptoms  of  diffuse  peritonitis.  Initial  shock  may  be 
absent.  ,  .    . 


THE  STOMACH  AND  DUODENUM  511 

Diagnosis  must  be  based  upon  the  suddenness  of  onset,  steady  progres- 
sion of  symptoms,  and  exploratory  operation. 

Wound  of  the  Stomach. — ^Yound  of  the  stomach  may  be  suggested 
by  vomiting  of  blood  after  traumatism,  and  the  nature  of  the  vulner- 
ating  body  and  the  direction  taken  by  it.  AMien  this  is  practicable,  the 
following  under  general  or  local  anesthesia  of  the  track  of  the  wound 
will  lead  to  a  correct  conclusion.  Perforation,  excepting  in  the  case 
of  modern  small  caliber  weapons  of  high  velocity,  is  denoted  shortly  by 
the  beginning  symptoms  of  a  local  or  diffuse  peritonitis. 

Foreign  Bodies  in  the  Stomach. — Foreign  bodies  in  the  stomach  are 
blocked  by  the  pylorus,  this  being  the  narrowest  part  of  the  alimentary 
canal.  Unless  these  bodies  cause  either  obstruction  or  ulceration,  they 
may  lie  for  years  and  cause  no  symptoms. 

The  diagnosis  is  based  upon  the  history,  the  use  of  the  x-rajs  when 
applicable,  and  the  symptoms  of  either  ulceration  or  obstruction. 

Acute  Dilatation  of  the  Stomach. — ^Acute  dilatation  may  follow  surfeit, 
anesthesia  (particularly  by  chloroform),  operation  (especially  on  the  gall 
passages),  traumatism,  infection  (particularly  pneumonia),  or  systemic 
intoxication. 

It  is  characterized  by  a  muscular  and  vasomotor  paresis,  the  former 
allowing  of  great  dilatation,  the  latter  of  a  copious  transudate  appearing 
as  an  offensive  but  not  feculent,  thin,  browai  vomitus. 

As  the  distended  stomach  forces  the  colon  and  the  small  intestines 
downward,  the  drag  upon  the  root  of  the  mesentery  and  the  superior 
mesenteric  vessels  completely  occludes  the  third  part  of  the  duodenum, 
thus  adding  to  the  dynamic  obstruction  a  mechanical  one.  This  mechan- 
ical obstruction  is  regarded  by  many  as  the  primary  cause  of  the  dilata- 
tion. 

Acute  dilatation  of  the  stomach  begins  with  sudden  acute  pain,  if  post- 
operative usually  within  the  first  twenty-four  hours,  at  times  not  for 
many  days.  This  pain  is  placed  in  or  about  the  stomach  and  is  asso- 
ciated with  moderate  tenderness.  The  stomach  rapidly  dilates  forming 
a  tense  resonant  swelling  most  marked  at  first  in  the  epigastric  region, 
later  filling  and  distending  the  entire  belly.  The  vomiting  is  recurrent 
and  profuse,  often  effortless.  The  constitutional  symptoms  are  pro- 
foundly adynamic,  the  pulse  becoming  weak  and  running,  the  respira- 
tions hurried  and  shallow,  the  face  gray  and  pinched. 

The  diagnosis  is  based  upon  the  early  epigastric  swelling,  the  character 
of  the  fluid  vomited  and  its  extraordinary  quantity,  and  the  beneficial 
effect  of  gastric  lavage  and,  at  times,  the  Trendelenburg  or  knee-chest 
position.     Stomach  splash  is  said  to  be  characteristic. 

This  affection  is  more  rapid  in  onset  than  peritonitis,  except  that  of 
the  perforative  type,  is  not  marked  by  the  characteristic  rigidity  or 
extreme  tenderness  of  the  latter  condition,  and  exhibits  promptly  the 
symptoms  of  an  overwhehning  toxemia  rather  than  those  of  an  inflamma- 
tory reaction. 

The  distinction  betw^een  the  paresis  and  dilatation  of  both  the  stomach 
and  intestines,  characteristic  of  the  terminal  stage  of  postoperative  diffuse 


512  THE  ABDOMEN 

peritonitis,  and  acute  dilatation  of  the  stomach,  in  the  absence  of  a 
demonstrable  infective  cause,  may  be  most  difficult.  The  prognosis  of 
this  condition  when  well  developed  is  grave. 

Pyloric  Obstruction. — Pyloric  obstruction  may  be  due  to  muscular 
hypertrophy  or  spasm,  or  both,  to  gastroptosis,  inflammatory  or  neoplastic 
infiltration,  cicatricial  contracture,  perigastric  adhesions,  or  pressure  of 
external  tumors.  The  symptoms  of  the  condition  bear  but  little  relation 
to  the  cause,  being  incident  to  the  amount  of  obstruction. 

Hypertrophic  stenosis  of  the  pylorus,  commonly  called  pylorospasm,  is 
essentially  an  affection  of  early  life,  developing  shortly  after  birth  (first 
month).  It  is  occasionally  observed  in  older  children,  exhibiting  a 
tendency  to  recur.  The  obstruction  is  partly  due  to  muscular  spasm 
of  the  hypertrophied  pyloric  sphincter  and  partly  to  redundant  folds  of 
mucous  membrane. 

It  is  characterized  by  colicky  pain,  vomiting,  visible  peristalsis,  the 
presence  of  a  movable  nodule  about  the  size  of  a  hazelnut  in  the  pyloric 
region  (80  per  cent,  of  cases,  Nicoll),  great  hunger,  wasting,  and  constipa- 
tion. The  vomiting  is  frequent,  explosive,  occurs  shortly  after  eating, 
and  is  free  from  bile,  mucus,  or  blood.  In  the  later  stages,  when  gastric 
dilatation  supervenes,  several  nursings  may  be  retained,  followed  by 
vomiting  in  quantity. 

Wasting  and  persistent  vomiting  are  so  common  in  improperly  nourished 
infants  that  the  diagnosis  of  pylorospasm  should  not  be  seriously  con- 
sidered until  the  effect  of  judicious  feeding  has  been  carefully  studied. 
The  cyclic  vomiting,  usually  accompanied  by  acetone  and  diacetic  acid  in 
the  urine,  is  characterized  by  its  comparatively  brief  recurring  paroxysms, 
with  intervals  of  complete  health.  The  vomiting  of  Henoch's  purpura 
(angioneurotic  edema)  is  characterized  by  its  sudden,  violent,  painful 
onset — often  blood  in  the  vomited  matter  and  the  stools  and  especially 
by  purpuric  skin  spots.  Cerebral  vomiting  is  in  children  usually 
attended  with  characteristic  symptoms  of  chronic  meningitis  (tuberculous 
or  syphilitic). 

Gastroptosis. — Gastroptosis,  usually  associated  with  enteroptosis,  right 
nephroptosis,  at  times  with  dilatation,  is  most  often  found  in  emaciated  and 
hysterical  females,  and,  even  though  extreme,  occasions  no  symptoms 
unless  there  be  angulation  at  the  pylorus.  The  pylorus  is  always  dis- 
placed downward  or  to  the  left  or  in  both  directions,  sinking  from  the 
level  of  the  first  lumbar  vertebra,  its  normal  position,  as  low  as  that  of 
the  fifth. 

The  condition  may  be  incident  to  congenital  pyloric  displacement  or 
abnormal  mobility,  colon  drag,  relaxed  gastrohepatic  ligament,  or  press- 
ure on  the  part  of  the  sagging  liver.  Above  the  lesser  curvature  the 
body  of  the  pancreas  may  be  felt  at  times  where  this  structure  crosses 
the  lumbar  vertebrae. 

The  symptoms  of  gastroptosis,  when  these  develop,  are  those  of  pyloric 
obstruction  and  ultimate  dilatation.  The  latter  may  become  recurringly 
acute.  Physical  'examination  supplemented  by  the  stomach  tube  and 
inflation  usually  satisfactorily  reveals  the  condition.     The  assured  diag- 


THE  STOMACH  AND  DUODENUM  513 

nosis  is,  however,  best  made  by  means  of  the  rr-rays  with  the  patient  in 
a  standing  position.  By  this  may  be  demonstrated  the  size,  shape, 
position,  and  mobihty  of  the  stomach 

Perigastric  Adhesions. — Perigastric  adhesions,  incident  to  a  local  peri- 
tonitis, usually  caused  by  gastric  ulcer  or  cholecystitis,  symptomless 
except  when  the  region  of  the  pylorus  is  involved,  are  characterized  by 
pain  at  times  constant,  but  most  marked  after  eating,  exaggerated 
peristalsis,  and  gastric  indigestion;  exceptionally  by  retention  of  food, 
dilatation,  and  vomiting.  The  diagnosis  is  based  upon  the  elimination 
of  non-surgical  causes  for  such  a  symptomatology,  the  history  of  a  pre- 
vious local  peritonitis,  and  the  fact  that  the  symptoms  are  stationary  or 
at  the  worst  but  slowly  (years)  progressive. 

Volvulus  of  the  Stomach. — Volvulus  of  the  stomach,  by  which  is  meant 
a  twist  of  the  organ  on  its  long  axis,  an  extremely  rare  accident,  is  only 
possible  in  conditions  of  gastroptosis.  It  is  characterized  by  pain, 
shocking  in  intensity,  rapid  distention  of  the  stomach,  and  inability  to 
vomit  or  eructate. 

Ulcer  of  the  Stomach. — ^Ulcer  of  the  stomach  may  appear  as  an  erosion 
so  slight  as  to  escape  even  postmortem  examination,  as  an  abrasion,  as 
acute  round  ulcer,  or  as  an  indurated  chronic  ulcer. 

The  acute  ulcer,  either  of  the  superficial  or  deep  type,  may  appear  in 
any  part  of  the  stomach,  particularly  on  the  posterior  wall  and  along  the 
lesser  curvature.  It  is  common  in  anemic  hysterical  young  women 
(about  twenty-five  years  old),  is  probably  a  local  expression  of  sepsis,  and, 
when  placed  on  the  anterior  wall,  is  prone  to  bleed  and  to  perforate. 

The  diagnosis  of  gastric  ulcer  is  based  upon  hemorrhage,  which  may 
be  occult,  slight,  profuse,  or  very  exceptionally  promptly  fatal;  pain,  often 
localized,  markedly  aggravated  by  taking  food,  and  relieved  by  vomiting 
or  stomach  lavage  or  orthoform  (Murdoch);  tenderness,  also  frequently 
well  localized,  hyperperistalsis,  and  excess  of  hydrochloric  acid  in  the 
gastric  content. 

When  the  ulcer  is  placed  near  the  pylorus,  and  either  by  its  hyperemia, 
induration,  or  cicatricial  contracture  causes  spasmodic  contracture  or 
pronounced  mechanical  narrowing  of  this  orifice,  there  will  be  added  to 
the  symptoms  just  noted  those  of  pyloric  obstruction  characterized  by 
retention  of  food,  hyperperistalsis,  dilatation,  absence  of  hydrochloric 
acid,  and  lactic  fermentation. 

As  symptoms  of  corroborative,  but  not  diagnostic  value,  anemia, 
emaciation,  constipation,  and  the  occasional  association  with  pulmonary 
tuberculosis  may  be  mentioned. 

Referred  pain  and  cutaneous  hyperalgesia  are  at  times  well  marked,  the 
seats  of  preference  being  over  the  ensiform  cartilage  or  to  one  side  of  it, 
and  at  a  point  in  line  with  the  scapular  angle  at  the  level  of  the  ninth 
dorsal  spine  (Head). 

The  one  symptom  upon  which  most  reliance  can  be  placed  is  hemor- 
rhage.    This,  if  profuse  and  vomited,  in  the  absence  of  adequate  trauma- 
tism, blood  dyscrasia,  or  vascular  back  pressure,  can  be  regarded  as  almost 
pathognomonic  of  ulceration.     Constantly  recurring  slight  hemorrhage, 
33 


514  THE  ABDOMEN 

shown  by  the  presence  of  occult  blood  in  the  vomited  matter  or  that 
drawn  from  the  stomach  by  lavage,  is  considered  equally  diagnostic 
in  the  absence  of  either  renal  or  hepatic  disease. 

Abdominal  arteriosclerosis  may  cause  acute  attaclcs  of  pain,  suggesting 
perforation,  or  may  be  characterized  by  recurring  paroxysms  closely 
simulating  those  of  ulcer  or  carcinoma.  Berger  reports  cases  suffering 
from  postprandial  pain,  emaciation,  and  bleeding,  in  which  an  autopsy 
failed  to  demonstrate  the  erosions  from  which  the  bleeding  came. 

Though  in  typical  cases  the  symptoms  of  gastric  ulcer  are  sufficiently 
characteristic  to  make  the  diagnosis  well-nigh  certain  even  in  the  absence 
of  exploration,  the  frequency  with  which  the  first  symptoms,  barring 
slight  digestive  disturbance,  are  those  of  acute  perforative  peritonitis, 
proves  that  ulcer  may  exist  without  offering  any  symptoms  upon  which 
even  a  probable  diagnosis  can  be  based. 

From  the  surgical  point  of  view  the  diagnosis  is  important  because  of 
the  complications  of  hemorrhage,  pyloric  obstruction,  diffuse  perforative 
peritonitis,  localized  peritonitis  with  gradual  extension  of  inflammation, 
perigastric  adhesions,  or  pus  formation.  These  conditions,  developing 
in  the  absence  of  a  preceding  history  of  gastric  ulcer,  can  be  distinguished 
as  to  their  etiology  only  on  the  basis  of  probability  and  exclusion. 

The  distinction  between  a  chronic  indurated  gastric  ulcer  and  gastric 
carcinoma  may  be  impossible  both  clinically  and  at  operation.  The 
subsequent  course  of  these  cases  shows  that  even  careful  microscopic 
examination  may  leave  the  examiner  in  error.  Hence,  when  radical 
surgical  procedure  is  possible,  this  in  doubtful  cases  should  take  the  form 
applicable  to  cancer. 

Carcinoma  of  the  Stomach. — Carcinoma  of  the  stomach  is  an  affection 
of  middle  age  and  old  age  without  sex  predilection,  usually  involving  the 
pylorus  and  lesser  curvature,  and  growing  toward  the  stomach  rather 
than  toward  the  duodenum.  It  may  develop  without  symptoms  other 
than  moderate  pain  and  those  of  gastric  indigestion,  until  a  palpable  tumor 
is  found,  unless  the  lesion  is  placed  near  the  pylorus  or  cardia  and  causes 
obstruction.  Under  such  circumstances  the  symptoms  do  not  differ 
from  those  of  obstruction  thus  placed  due  to  other  causes  except  for 
their  rapid  (weeks  or  months)  and  inevitable  progression. 

Apparently  causeless  and  progressive  loss  of  weight  and  toxic  anemia 
in  a  person  who  has  reached  middle  age,  associated  with  persistent 
gastric  pain  of  moderate  severity,  often  localized  tenderness,  and  gastric 
indigestion  resistant  to  carefully  regulated  diet,  are  regarded  as  sufficient 
evidences  of  gastric  carcinoma,  particularly  if  associated  with  habitual 
absence  or  deficiency  of  hydrochloric  acid  and  occult  or  obvious  blood  in 
the  vomitus  or  the  stomach  washings. 

The  symptoms  upon  which  diagnosis  is  usually  based  are:  Pain; 
emaciation ;  frequent  vomiting  of  gastric  contents,  exhibiting  the  coffee- 
ground  appearance  of  slight  hemorrhage  and  deficient  in  hydrochloric 
acid,  with  lactic  acid  present  and  a  large  bacterial  content,  particularly 
the  Oppler-Boas  bacillus;  later,  vomiting  of  food  taken  many  hours 
before,   and  with  the  demonstrable  signs   of  gastric  dilatation;   and 


THE  STOMACH  AND  DUODENUM  515 

finally,  the  detection  of  a  tumor,  hard,  rounded,  nodular,  if  the  adjacent 
lymph  glands  are  extensively  involved,  usually  movable  and  best 
palpated  when  the  stomach  is  empty. 

These,  with  the  exception  of  tumor,  are  the  symptoms  of  pyloric 
stenosis,  and  may  be  equally  well  marked  from  obstruction  of  equal 
degree  due  to  other  causes.  When  the  symptomatology  is  complete  and 
unmistakable  the  time  for  radical  operation  has  generally  passed, 

Hypochlorhydria  is  supposed  to  be  particularly  characteristic  of  cancer, 
and  is  noted  even  when  this  lesion  is  non-obstructive.  Hydrochloric 
acid  is  subnormal  in  quantity,  however,  in  many  apparently  healthy 
persons. 

The  distinction  between  carcinoma  and  an  indurated  and  obstructing 
ulcer  can  often  not  be  made  even  at  operation,  the  ultimate  decision 
depending  on  microscopic  examination. 

An  early  positive  diagnosis  of  cancer  can  be  made  only  by  exploratory 
operation. 

Hourglass  Stomach. — Hourglass  stomach,  possibly  congenital,  usually 
due  to  cicatricial  contracture  or  infiltration  of  carcinoma,  exhibits,  as  a 
rule,  the  constriction  near  the  pylorus,  the  fundus  being  dilated.  If  the 
pylorus  is  also  narrowed,  both  gastric  pouches  may  exhibit  dilatation. 
It  is  characterized  by  the  symptoms  of  obstruction.  The  sudden  return 
in  quantity  of  turbid  fluid  through  the  tube  after  the  stomach  apparently 
has  been  washed  clear  is  characteristic.  Palpation  and  percussion  of 
the  inflated  stomach  at  times  give  evidence  of  the  condition.  It  is  best 
detected  by  the  x-ray  after  the  ingestion  of  bismuth. 

When  both  the  pyloric  and  the  cardiac  pouch  are  dilated  even  an 
exploratory  operation  may  fail  to  reveal  the  true  condition  of  affairs 
unless  the  exploration  be  thorough. 

Sclerosing  Gastritis. — Sclerosing  gastritis  (linitis,  rare)  is  characterized 
by  an  enormous  fibrous  thickening  of  the  gastric  walls,  with  consequent 
encroachment  upon  the  lumen  of  the  viscus.  Its  symptoms  are  those  of 
inveterate  gastric  indigestion,  pain,  often  severe,  paroxysmal  and  most 
marked  after  eating,  and  vomiting,  never  profuse.  It  is  slow  in  progress 
(years),  the  rigid  gastric  walls  cannot  be  demonstrably  inflated  though 
efforts  to  accomplish  this  cause  agonizing  pain,  and  the  hard,  contracted 
stomach  may  be  difficult  to  find  even  on  exploration. 

Carcinoma  of  the  Duodenum. — Carcinoma  of  the  duodenum,  rare  as 
compared  to  this  affection  of  the  stomach,  is,  if  obstructive,  attended  Tvdth 
the  symptoms  of  pyloric  stenos's,  nor  can  it  be  differentiated  except  by 
exploration. 

When  placed  at  or  near  the  papilla,  the  symptoms  are  those  of  steadily 
progressing  biliary  obstruction,  associated,  in  the  absence  of  calculi,  with 
little  or  no  biliary  colic,  with  a  distended  gall-bladder  and  the  evidences 
in  the  stools  of  absent  or  deficient  pancreatic  secretion. 

Duodenal  Ulcer. — Duodenal  ulcer,  an  affection  of  middle-aged  men 
(about  forty  years),  developing  usually  on  the  anterior  wall  of  the 
bowel  near  the  pylorus,  is  probably  symptomless,  as  a  rule,  its  presence 


516  THE  ABDOMEN 

not  being  suspected  until  the  complications  of  perforation  or  hemorrhage 
occur. 

Diagnosis  of  the  condition  in  the  absence  of  these  complications  is 
based  upon  pain  which,  if  localized,  is  often  placed  to  the  right  of  the 
ensiform  cartilage  and  slightly  below  it,  tenderness  on  deep  pressure 
at  this  same  point,  and  blood  in  the  stools  or  the  vomit,  or  both.  Eruc- 
tation, recurring  vomiting,  and  impaired  general  health  are  corroborative 
symptoms.  The  one  which  is  most  characteristic  is  the  effect  of  food 
on  pain;  the  latter  is  relieved  by  eating  a  full  meal,  but  recurs  some  hours 
later;  vomiting  and  gastric  lavage  also  give  relief. 

The  distinction  between  duodenal  ulcer  and  hepatic  colic  is  based 
upon  the  slower  onset  and  less  severity  of  the  pain  attacks  of  the  former, 
the  alleviating  effect  of  eating,  alkalies,  vomiting,  or  lavage,  the  presence 
of  blood  in  the  stools  or  vomited  matter,  the  usual  hyperacidity  of  the 
latter,  and  constipation. 

The  local  tenderness  and  rigidity  are  in  about  the  same  region  in 
both  affections  and  in  each  jaundice  may  be  present;  the  backward 
and  upward  radiations  and  pain  on  deep  pressure  are  characteristic  of 
hepatic  colic,  while  referred  surface  pain  and  hyperalgesia  in  the  right 
upper  abdominal  quadrant  are  more  marked  in  ulcer. 

THE  LIVER. 

The  liver  occupies  the  right  upper  abdominal  quadrant,  extending 
about  two  inches  beyond  the  midline  into  the  left  upper  quadrant. 
The  surface  marking  of  its  upper  border,  which  is  moulded  to  the 
diaphragm,  forms  a  curved  line  convex  upward,  extending  from  a  point 
one  and  a  half  inch  to  the  left  of  the  base  of  the  ensiform  to  a  point  half 
an  inch  below  the  right  nipple  (middle  of  the  fourth  intercostal  space), 
thence  to  the  ninth  interspace  in  the  scapular  line.  Its  lower  anterior 
margin  corresponds  with  the  costal  border  and  a  line  drawn  from  the 
ninth  costal  cartilage  to  a  point  two  inches  to  the  left  of  the  base  of  the 
ensiform  cartilage. 

The  liver  is  held  in  place  by  intra-abdominal  pressure,  by  the  falciform 
ligament  extending  practically  from  the  diaphragm  to  the  umbilicus  and 
completely  dividing  the  subphrenic  space  into  two  parts,  and  by  its  vascular 
attachments  to  the  vena  cava. 

The  blood  supply  of  the  liver  is  through  the  hepatic  artery.  The  portal 
vein  brings  blood  from  the  spleen,  pancreas,  and  gastro-intestinal  tract. 
These  two  systems  finally  merge  into  the  hepatic  veins,  which  are  without 
valves  and  which  empty  directly  into  the  vena  cava. 

The  lymphatics  empty  into  infradiaphragmaticand  supradiaphragmatic 
nodes  placed  about  the  vena  cava,  into  those  placed  about  the  celiac  axis, 
and  into  those  lying  in  the  region  of  the  cardiac  end  of  the  stomach. 

The  nerve  supply  is  from  the  solar  plexus,  the  left  pneumogastric,  and 
the  right  phrenic. 

The  gall-bladder,  a  diverticulum  from  the  gall  tract,  from  three  to 
four  inches  long,  with  a  capacity  of  on^  ^nd  a  half  ounces,  lies  with  its 


THE  LIVER  517 

fundus  nearest  the  anterior  abdominal  wall  at  the  point  of  crossing 
the  costal  margin  by  a  line  drawn  from  the  right  nipple  in  the  male 
to  the  umbilicus  (ninth  costal  cartilage).  It  is  usually  attached  to 
the  liver  along  its  upper  surface.  Occasionally  it  is  provided  with  a 
distinct  mesentery.  Its  duct,  about  one  and  a  half  inches  long, 
often  sharply  angled  as  it  enters  the  common  duct,  presents  a  lumen  so 
obstructed  by  mucous  folds  as  to  make  the  passing  of  a  probe  difficult 
or  impossible. 

The  gall-bladder  is  an  unessential  organ,  provided  with  elastic  but 
extremely  strong  walls.  It  is  probably  a  provision  for  a  continuous 
slow  secretion,  which  is  intermittently  stimulated  to  hyperactivity  when 
it  is  needed  in  the  process  of  duodenal  digestion.  It  has  a  secretion  of 
its  own  independent  of  the  bile  which  it  contains. 

In  the  transverse  fissure  of  the  liver,  two  ducts,  each  coming  from 
its  own  lobe,  unite  to  form  the  hepatic  duct,  which,  after  a  course  in 
the  gastrohepatic  omentum  of  from  one  to  two  inches,  is  joined  by 
the  cystic  to  form  the  common  duct. 

The  common  duct  passes  downward,  either  through  the  head  of  the 
pancreas  or  between  this  organ  and  the  duodenum,  and,  after  dilating 
into  the  ampulla  of  Vater  and  being  joined  by  the  pancreatic  duct, 
discharges  through  a  narrow,  valve-like  opening  into  the  lumen  of  the 
duodenum. 

Along  the  course  of  the  common  duct,  and  particularly  at  the  angle 
or  junction  between  the  cystic  and  the  hepatic  duct,  are  found  lymph 
glands. 

The  liver  secretes  two  to  three  pints  of  bile  in  twenty-four  hours. 
The  flow  is  constant,  but  is  increased  by  eating  and  by  secretin. 

The  bile  is  helpful,  but  not  essential,  to  digestion.  With  the  bile  are 
excreted  organisms,  mostly  dead,  carried  to  the  liver  through  the  portal 
circulation,  and  at  times  toxic  substances  of  such  virulence  as  to  cause 
ulceration  of  the  intestine. 

Among  the  metabolic  functions  of  the  liver  the  formation  of  glycogen 
and  urea  are  conspicuous. 

The  cardinal  symptoms  of  surgical  liver  affections  are  tenderness, 
pain,  tumor,  jaundice,  gastric  indigestion  and  the  constitutional  symp- 
toms of  infection  or  impaired  metabolism.  When  ascites,  together  with 
varicosities  of  the  hemorrhoidal,  superficial  epigastric,  and  esophageal 
veins,  develops  the  case  is  usually  no  longer  a  surgical  one,  though  a 
stone  pressing  on  the  portal  vein  may  cause  these  symptoms. 

The  pain  of  liver  affections  is  a  dull  ache,  subject  to  paroxysmal 
exacerbation,  often  traceable  to  errors  in  diet.  It  is  felt  in  the  region  of 
the  liver  or  near  the  midline  at  the  tip  of  the  ensiform  cartilage.  Its 
radiation  is  toward  the  central  line,  backward  or  upward  and  backward, 
to  the  right,  exceptionally  to  the  left,  shoulder  (phrenic  and  superior 
acromial  nerves). 

When  due  to  gallstone  obstruction  the  pain  is  sudden  in  onset,  ex- 
tremely severe,  attended  with  early  vomiting,  which  may  or  may  not 
bring  relief,  and  accompanied  by  tenderness  in  the  gall-bladder  region. 


518  THE  ABDOMEN 

When  due  to  acute  inflammation  of  the  investing  peritoneum,  the  pain  is 
attended  with  the  tenderness  and  rigidity  of  local  peritonitis. 

The  tenderness  of  liver  affections  is  elicited  by  direct  palpation,  and 
particularly  in  case  of  the  gall-bladder  by  pressing  the  fingers  of  the 
examining  hand  deeply  upward  and  backward  in  the  gall-bladder  region 
during  expiration.  The  following  inspiration  will  be  abruptly  arrested 
(Murphy). 

Tenderness  thus  elicited  may  be  referred  to  the  midline. 

Protective  rigidity  of  the  upper  portion  of  the  right  rectus  is  in  itself 
diagnostic  of  deep  tenderness. 

The  tumor  of  hepatic  affections  is  detected  by  direct  palpation  and 
by  percussion,  the  area  of  dulness  being  convex  upward  when  due  to 
solid  growths  or  fluid  accumulation  below  the  diaphragm. 

Jaundice,  earliest  detected  in  the  serum  of  blood  drawn  into  a  capillary 
tube  and  in  the  urine  and  first  seen  in  the  conjunctiva,  is  a  symptom 
of  obstruction  of  the  ducts.  It  is  usually  absent  in  stones  confined  to  the 
gall-bladder,  ephemeral  when  due  to  catarrhal  swelling;  is  inconstant  in 
abscess  or  neoplasm,  or  granuloma,  depending  upon  the  amount  of 
direct  pressure;  is  intermittently  recurring  and  attended  with  paroxysms 
of  pain  in  gallstone  disease  involving  the  common  duct;  is  persistent  and 
slowly  progressive  in  carcinoma  or  chronic  inflammation  of  the  head  of 
the  pancreas,  or  in  duct  cancer. 

Malformation.— Transposition  of  the  Liver. — ^This  organ,  being  placed 
to  the  left  side,  is  usually  associated  with  malposition  of  other  organs. 

An  accessory  lobe  in  the  form  of  a  tongue-like  projection  (Riedel's 
lobe)  extending  downward  over  the  gall-bladder  in  itself  causes  no 
symptoms.  Its  smooth  outline,  rounded  borders,  position  immediately 
beneath  the  abdominal  wall,  attachment  to  the  liver,  and  free  respiratory 
movements  are  characteristic. 

Corset  Liver. — Corset  liver  is  characterized  by  the  formation  of  a 
constriction  in  the  right  lobe,  dividing  this  portion  of  the  liver  into  two 
masses  separated  by  a  groove.  It  is  usually  observed  in  women  given 
to  tight  lacing.     The  diagnostic  symptoms  are  those  of  Riedel's  lobe. 

Movable  Liver. — Movable  liver,  hepatoptosis,  usually  associated  with 
general  visceral  ptosis,  is  characterized  by  a  downward  displacement 
with  forward  rotation  of  the  diaphragmatic  surface  of  the  organ.  The 
characteristic  sharp  edge  and  smooth,  dome-like  surface  associated  with 
percussion  resonance  in  the  liver  region  establish  the  diagnosis. 

Trauma  of  the  Liver. — Severe  subcutaneous  injury  is  characterized 
by  shock  and  symptoms  of  hemorrhage,  the  liver  being  easily  ruptured 
because  of  its  friability  and  bleeding  freely  because  of  its  vascularity. 
Absolute  diagnosis  must  be  made  by  operation.  Rupture  of  the  gall 
ducts  has  usually  caused  rapid  jaundice  and  the  symptoms  of  a  subacute 
diffuse  peritonitis. 

Symmetrical  Enlargement. — Symmetrical  enlargement  of  the  liver 
appears  most  frequently  in  the  form  of  cirrhosis,  an  expression  of  inter- 
stitial hepatitis  due  to  alcohol  and  other  forms  of  chronic  poisoning. 
It  is  occasionally  associated  with  peritoneal  and  intestinal  tuberculosis. 


THE  LIVER  519 

It  is  characterized  by  jaundice,  big,  tender,  uniformly  enlarged  liver, 
and  constitutional  symptoms  incident  to  this  condition. 

The  symmetrically  enlarged  amyloid  liver  consequent  on  prolonged 
suppuration,  exceptionally  in  syphilitic  infection,  exhibits  neither 
jaundice,  pain,  nor  tenderness.  The  stool  may  be  light  colored  because 
of  the  diminished  secretion  of  bile. 

Passive  congestion  incident  to  venous  back  pressure  from  circulatory 
failure,  especially  that  incident  to  tricuspid  insufficiency,  is  characterized 
by  tender,  often  pulsating,  hepatic  enlargement. 

Banti's  disease  or  splenic  anemia  is  characterized  by  enlarged  liver, 
secondary  to  that  of  the  spleen.  This  term  probably  includes  a  number 
of  affections  of  different  origin,  among  which  may  be  mentioned  cirrhosis 
of  the  liver  with  early  splenic  involvement,  malaria,  and  congenital 
syphilis. 

Cysts,  Tumors,  and  Infections  of  the  Liver. — Echinococcus  Cysts. 
— Echinococcus  cysts  are  usually  multilocular,  placed  in  the  right  lobe 
on  its  upper  surface,  can  be  detected  only  by  slow  growth,  and  not 
then  unless  they  approach  the  surface  anteriorly,  project  upward  at  the 
expense  of  the  thoracic  cavity,  or  become  acutely  inflamed. 

Diagnosis  must  be  made  by  operation. 

Dermoid  cysts  have  been  reported,  but  must  be  diagnosticated  by 
operation. 

Carcinoma. — Carcinoma,  usually  secondary  to  cancer  of  the  stomach, 
rectum,  or  breast,  exceptionally  primary,  is  characterized  by  dull,  deep- 
seated  pain,  often  some  tenderness,  and  the  detection  of  a  nodular 
growth.  The  distinction  from  gumma  must  be  made  by  the  associated 
history  and  the  result  of  the  therapeutic  test. 

Sarcoma. — Sarcoma,  usually  secondary,  occurs,  as  a  rule,  in  younger 
people,  and  grows  more  rapidly.  The  diagnosis  depends  upon  the 
finding  of  a  primary  focus,  usually  upon  operation. 

Angioma  or  Lymphangioma. — Angioma  or  lymphangioma  (rare) 
might  be  suggested  by  marked  changes  in  consistency  and  size  without 
obvious  cause.  The  diagnosis  is  usually  formulated  at  operation  or 
autopsy. 

Syphilis  of  the  Liver. — Syphilis  of  the  liver  in  the  form  of  a  diffuse 
infiltration,  producing  a  uniform  enlargement,  sometimes  accompanied 
by  nausea,  vomiting,  and  fever,  may  simulate  abscess.  The  diagnosis 
must  be  based  on  the  history  and  the  therapeutic  test. 

Gummata  form  circumscribed  hard  tumors,  palpable  along  the  anterior 
border,  which  may  or  may  not  be  painful  and  tender.  The  distinction 
from  cancer  by  palpation  is  impossible,  and  must  be  based  upon  the 
previous  history  of  syphilis,  the  presence  of  other  specific  lesions  or 
traces  of  them,  the  absence  of  a  primary  or  demonstrable  cancer 
focus,  or  symptoms  suggesting  the  presence  of  such  a  one  and  the 
beneficial  effect  of  mercuric  treatment. 

Tuberculosis. — Tuberculosis  is  always  secondary,  and  the  same  is  true 
of  actinomycosis.  In  either  case  a  tumor  may  form  with  the  local  and 
general  symptoms  of  subacute  abscess.    Diagnosis  depends  upon  micro- 


520  THE  ABDOMEN 

scopic  examination  of  the  discharge,  associated  with  the  history  of  the 
case. 

Abscess. — Abscess  of  the  hver  due  to  trauma,  direct  extension,  or  in- 
fection carried  from  the  gastro-intestinal  tract  (appendicitis,  typhoid 
ulceration,  amebic  dysentery),  either  through  the  portal  vein,  the  lymph 
channels,  or  the  common  duct,  or  infection  carried  through  the  hepatic 
artery  (osteomyelitis,  pyemia),  may  be  single  or  multiple,  usually  the 
latter,  excepting  when  the  abscess  is  secondary  to  trauma,  direct  ex- 
tension from  perihepatic  suppuration,  or  amebic  dysentery. 

The  condition  is  characterized  by  local  pain,  tenderness,  usually  general 
enlargement  of  the  liver,  and  the  gastro-intestinal,  systemic,  and  blood 
symptoms  of  infection.  Jaundice  may  or  may  not  be  present,  but  is 
usually  observed  to  a  slight  degree.  Pain  and  friction  sounds  of  peri- 
hepatitis are  at  times  noted.  Upward  extension  is  characterized  by  the 
symptoms  of  a  basal  pleurisy  on  the  right  side.  This  may  be  followed 
by  purulent  expectoration  due  to  rupture  of  the  abscess  through  the 
lung  into  a  bronchus.     Pain  radiations  are  backward  and  upward. 

The  symptoms  in  the  case  of  single  amebic  abscess,  usually  placed  on 
the  upper  surface,  may  remain  latent  for  months,  percussion  demon- 
strating an  increased  area  of  dulness  extending  dome-like  into  the  chest. 
The  diagnosis  is  often  not  suspected  until  edema  and  tenderness  indicate 
surface  pointing. 

When  the  abscesses  are  multiple  (suppurative  cholangitis)  the  consti- 
tutional symptoms  of  profound  infection  far  outweigh  those  of  local 
reactive  inflammation. 


THE  GALL-BLADDER. 

The  gall-bladder  may  be  absent,  bifid,  or  hourglass  in  shape. 

Lijuries. — Injuries  to  the  gall-bladder  or  ducts,  barring  direct  wound, 
are  not  common,  except  in  connection  with  extensive  and  usually  fatal 
trauma  to  neighboring  organs.  The  immediate  usual  sequel  is  peri- 
tonitis; in  the  absence  of  this,  the  evidence  of  free  fluid  in  the  peritoneal 
cavity  and  jaundice  from  bile  absorption. 

Distention. — Distention  of  the  gall-bladder  may  be  due  to  the  retention 
of  its  own  secretion  incident  to  blocking  of  its  pelvis  or  duct,  or  to  pro- 
longed backing  of  the  bile  into  it  because  of  obstruction  to  the  common 
duct. 

It  is  characterized  by  the  presence  of  a  rounded,  smooth  tumor  in  the 
gall-bladder  region,  growing  downward  and  inward  toward  the  umbilicus, 
and  usually  neither  tender  nor  painful. 

The  position  of  the  tumor  above  or  in  front  of  the  colon  and  not  pal- 
pable in  the  flank,  its  participation  in  the  respiratory  movements  of  the 
liver,  and  its  attachment  to  the  latter  organ  distinguish  it  sufficiently 
from  renal  enlargements.  When  the  distention  has  become  so  great 
as  to  form  a  large  tumor  filling  the  greater  portion  of  the  right  abdomen, 
or  even  overlapping  the  middle  line,  the  distinction  from  renal  tumor, 


THE  GALL-BLADDER  521 

or  even  cysts  of  pelvic  origin,  is  more  difficult.  The  history  of  the  de- 
velopment of  the  growth,  the  attachment  of  its  pedicle  to  the  liver,  the 
comparatively  moderate  bulging  in  the  flank,  are  all  elements  favoring 
its  gall-bladder  origin.  This  form  of  distended  gall-bladder  is  usually 
not  accompanied  by  jaundice,  but,  if  the  latter  exists,  it  is  moderate 
in  degree. 

When  the  distention  is  due  to  obstruction  of  the  common  duct  there 
is  always  associated  an  intense  jaundice.  ' 

Cholecystitis. — Cholecystitis,  usually  associated  with  calculi,  may 
appear  in  the  catarrhal,  suppurative,  or  necrotic  form.  It  is  character- 
ized by  pain,  tumor,  local  tenderness  and  rigidity,  and  constitutional 
symptoms  of  infection.     Often,  also,  by  a  moderate  jaundice. 

The  acute,  suppurative  form,  commonly  secondary  to  typhoid  fever, 
pneumonia,  or  appendicitis,  is  characterized  by  pronounced  symptoms 
of  both  local  peritonitis  and  constitutional  infection. 

Gangrene  or  perforation  may  be  characterized  by  the  development 
of  either  the  symptoms  of  local  abscess  of  hyperacute  type,  or  those  of 
diffuse  peritonitis. 

Membranous  cholecystitis  exhibits  much  the  symptoms  of  gallstone 
disease,  i.  e.,  colic  and  local  tenderness  and  rigidity.  This  rare  affec- 
tion might  be  suggested  by  the  finding  of  membranes  in  the  stools 
since  it  is  associated  with  membranous  enteritis. 

The  rupture  of  a  gall-bladder  abscess  may  occur  externally,  usually 
below  the  border  of  the  ribs  or  in  the  umbilical  region,  into  the  colon, 
the  duodenum,  the  stomach,  the  subphrenic  space,  or  the  renal  pouch. 

Cholelithiasis. — Stones  in  the  Gall-bladder. — Stones,  usually  formed  in 
the  gall-bladder  of  physically  indolent,  gouty,  fat  people,  particularly 
w^omen  (3  to  1)  past  the  age  of  thirty-five,  are  due  to  infection  which 
in  turn  is  often  secondary  to  typhoid  fever  or  appendicitis. 

\ATien  there  is  no  effort  made  to  extrude  them  from  the  bladder,  they 
may  cause  no  sjmiptoms  other  than  heaviness  after  eating,  gaseous 
eructations,  deep  pain,  referred  to  gastric  indigestion,  and  the  symptoms 
of  pyloric  stenosis  of  moderate  degree. 

When  stones  in  the  gall-bladder  cause  symptoms  which  may  be 
regarded  as  diagnostic,  they  are  expressed  either  in  the  form  of  pain, 
harassing,  deep,  diffuse,  in  the  liver  region,  associated  with  gastric 
indigestion  and  often  a  dorsal  reference  (to  the  right  of  the  eleventh 
and  twelfth  spinous  processes);  tenderness  elicited  by  hooking  the 
fingers  under  the  rib  at  the  ninth  costal  cartilage  during  expiration 
and  directing  the  patient  to  take  a  deep  breath,  sometimes  referred  to 
the  epigastrium;  recurring  fever  paroxysms  exhibiting  a  sudden  jump 
and  equally  sudden  drop  of  temperature,  the  steeple  chart;  or  in  the 
form  of  colic,  characterized  by  the  rapid  or  sudden  onset  of  severe 
crippling  often  shocking  pain  in  the  liver  region,  with  radiations  back- 
w^ard  and  upward,  tenderness  readily  elicited  in  the  gall-bladder  region 
unless  the  rectus  be  protectively  rigid,  nausea,  vomiting,  which  may 
or  may  not  bring  relief,  intestinal  tympany,  and  constipation. 

Fever  is  present  or  absent  in  accordance  with  the  degree  of  infection 


522  THE  ABDOMEN 

and  the  completeness  of  obstruction.  The  attack  may  last  minutes, 
hours,  or  days,  and  be  paroxysmally  recurrent  in  type.  Convalescence 
is,  considering  the  severity,  astonishingly  rapid  and  complete. 

Following  the  attack,  soreness  and  tenderness  last  for  several  days. 
Relief  of  acute  symptoms,  prompt  or  gradual,  signifies  that  an  obstructing 
stone  has  become  so  no  longer,  either  because  it  has  passed  on  or  has 
dropped  back  into  the  gall-bladder. 

In  the  cases  characterized  by  constant  or  recurring  pain,  but  not  of 
crippling  intensity,  the  distinction  between  gallstone  and  gastric  or 
duodenal  ulcer  will  depend  upon  the  more  nearly  midline  seat  of  pain 
and  local  tenderness  in  the  latter  conditions,  the  finding  of  obvious  or 
occult  blood  in  the  material  expressed  from  the  stomach,  or  obtained 
by  examination  of  the  stools,  the  prompt,  decided,  and  usually  certain 
aggravation  of  pain  incident  to  taking  food  in  the  case  of  gastric  ulcer, 
its  immediate  alleviation  and  subsequent  (one  or  two  hours)  exacerba- 
tion in  case  of  duodenal  ulcer,  the  more  pronounced  effect  on  general 
nutrition  of  ulcer,  and  the  prompt  and  usual  relief  incident  to  vomiting 
or  the  administration  of  chloretone. 

Catarrhal  jaundice  may  be  present  in  either  duodenal  ulcer  or  stone 
in  the  gall-bladder,  and  hyperchlorhydria  is  common  to  both  conditions, 
particularly  in  the  case  of  stone  as  a  prodrome  to  an  attack  of  colic. 
'  The  pain  due  to  efforts  to  pass  a  stone  through  the  cystic  duct,  and 
the  obstruction  incident  thereto  is  more  sudden  in  onset  and  more 
crippling  in  intensity  than  that  incident  to  ulcer.  Attended  as  it  often 
is  with  shock,  vomiting,  and  tympany,  it  suggests  rather  a  perforative 
peritonitis.  The  distinction  from  this  condition  is,  in  the  early  stages, 
suggested  by  the  history  of  a  previous  attack,  by  the  direction  of  pain 
radiation,  and  by  the  fairly  sharp  localization  of  tenderness  over  the 
gall-bladder;  shortly  by  the  absence  of  symptoms  of  a  rapidly  pro- 
gressing diffuse  peritonitis. 

From  renal  pain  gallstone  colic  is  distinguished  by  its  upward  and 
backward  pain  radiations,  absence  of  tenderness  in  the  ileocostal  angle, 
and  usually  by  urinary  findings  in  the  latter  condition. 

The  distinction  between  hepatic  colic  and  the  abdominal  crises  of 
ataxia,  of  angeoneurosis,  or  the  referred  pain  of  thoracic  infections  is 
referred  to  elsewhere. 

Stones  in  the  gall-bladder,  or  its  duct,  may  be  complicated  by  hydrops, 
or  acute  or  chronic  cholecystitis;  usually  when  they  excite  symptoms, 
often  in  the  absence  of  these,  by  local  peritonitis  with  the  formation  of 
adhesions  to  the  omentum,  colon,  stomach,  and  duodenum;  occasion- 
ally by  fistulous  openings  into  hollow  viscera,  or  pericystic  abscess 
formation;  occasionally  by  catarrhal  cholangitis  of  sufficient  intensity 
to  cause  intermittent  jaundice;  exceptionally  by  portal  phlebitis,  inci- 
dent to  direct  pressure,  with  ascites,  and,  if  the  common  duct  also  be 
involved,  pronounced  and  continuous  jaundice. 

Stones  in  the  hepatic  or  the  common  duct  are  characterized  by  much 
the  same  symptoms  as  those  of  stone  in  the  cystic  duct,  with  the  usual 
addition  of  jaundice,  either  intermittent  or  continuous,  which  varies  in 


THE  PANCREAS  523 

intensity  from  day  to  day  or  even  in  the  same  day,  which  deepens 
with  each  attack  of  pain,  and  fever,  coming  on  with  the  jaundice-pain 
paroxysms,  intermittent  in  type,  and  exhibiting  the  steeple  fluctuation, 
and  deterioration  in  weight  and  strength,  which  may  be  rapid  (weeks, 
months)  or  slow  (years). 

The  gall-bladder  is  usually  contracted,  adherent,  and  cannot  be  pal- 
pated; the  liver  is  enlarged,  often  markedly  so,  and  particularly  during 
acute  pain  and  jaundice  attacks.  The  stools  are  putty  colored  and 
fatty  and  the  urine  is  bile  stained. 

Stones  in  the  common  duct  are  complicated  by  cholangitis,  which 
may  become  widespread,  suppurative,  and  rapidly  fatal,  by  ulceration 
and  abscess  formation,  or  discharge  into  surrounding  hollow  viscera, 
by  phlebitis  and  ascites,  and  particularly  by  acute,  subacute,  or  chronic 
pancreatitis. 

From  cholangitis,  without  stones,  the  diagnosis  is  mainly  based  upon 
the  history  of  recurring  attacks  of  pain. 

From  obstruction  of  the  common  duct  by  malignant  growth  or  pan- 
creatic infiltration,  by  the  fatally  progressive  nature  of  the  jaundice, 
in  the  latter  case,  the  more  complete  and  permanent  occlusion  of  the 
duct  as  shown  by  examination  of  the  stools,  the  palpable  enlargement 
of  the  gall-bladder,  and  the  absence  of  a  history  of  recurring  attacks 
of  hepatic  colic. 

Aneurysm  of  the  hepatic  artery  may  cause  by  pressure  both  the  colicky 
pain,  the  gastric  disturbances,  and  the  jaundice  characteristic  of  duct 
stone.  Theoretically,  the  detection  of  a  pulsating  tumor,  giving  a 
characteristic  bruit,  should  establish  the  diagnosis. 

Cancer  of  the  Gall-bladder. — Cancer  of  the  gall-bladder,  usually  due  to 
stone,  is  characterized,  aside  from  the  symptoms  of  this  latter  con- 
dition, by  nodular  tumor  in  the  gall-bladder  region.  Diagnosis  should 
be  made  by  operation  and  before  tumor  becomes  demonstrable. 

Gall-bladder  cancer,  secondary  to  infiltration  of  the  liver,  usually 
gives  no  history  of  stone,  and  is  of  minor  moment  as  compared  to  the 
primary  disease.  In  either  case,  if  the  cystic  duct  be  occluded,  acute 
suppurative  cholecystitis,  with  its  characteristic  symptoms,  may  develop 
and  mask  the  original  lesion. 

Occlusion  of  the  common  duct  by  cancer  of  the  fapilla  cannot  be 
distinguished  from  that  due  to  stone,  since  it  is  usually  secondary  to 
this  condition,  except  for  the  lack  of  intermittence  in  obstructive  symp- 
toms and  the  development  of  ascites  from  vein  involvement.  The 
complicating  gastric  disturbance,  the  constitutional  manifestations  of 
cholangitis,  and  the  symptoms  and  signs  of  pancreatic  involvement,  are 
the  same  in  both  affections 


THE  PANCREAS. 

The  pancreas  is  a  lobulated,  postperitoneal  gland,  without  fibrous 
capsule,  the  head  of  which  fits  into  the  loop  made  by  the  V-shaped  duo- 


524  THE  ABDOMEN 

denum  or  may  completely  surround  this  portion  of  the  gut,  and  the  neck 
and  body  of  which  pass  almost  transversely  across  the  abdomen  behind 
the  stomach  on  a  level  with  the  body  of  the  first  lumbar  vertebra  about 
three  inches  above  the  umbilicus.  There  may  be  aberrant  growths 
of  normal  tissue  connected  with  the  substance  of  the  gland  by  ducts 
only,  or  an  accessory  pancreas  without  any  connection  with  the  gland 
may  develop  in  the  gastric  or  intestinal  walls. 

The  main  duct,  the  canal  of  Wirsung,  traverses  the  entire  length  of 
the  gland,  parelleling  the  common  bile  duct  as  it  approaches  the  latter 
and  finally  uniting  with  it  in  the  duodenal  wall  to  form  the  ampulla  of 
Vater.  The  accessory  duct  (duct  of  Santorini),  communicating  with  the 
main  duct  at  the  neck  of  the  gland  and  collecting  the  secretion  from  its 
head,  discharges  into  the  duodenum  by  a  separate  orifice  placed  about 
three-quarters  of  an  inch  above  the  opening  of  the  ampulla  of  Vater. 

The  common  bile  duct  and  the  pancreatic  duct  may  unite  at  some 
distance  from  the  duodenum  or  may  open  side  by  side  at  the  apex  of 
the  caruncle. 

Between  the  head  of  the  pancreas  and  the  duodenum,  or  completely 
surrounded  by  pancreatic  tissue,  lies  the  common  bile  duct.  The  pan- 
creas is  encircled  by  anastomosing  arteries  derived  from  the  splenic 
hepatic  and  superior  mesenteric  vessels;  the  veins  pass  directly  into 
the  splenic  and  superior  mesenteric  veins.  Nerves  are  from  the  vagi  and 
the  solar  plexus.  The  lymphatics  pass  into  the  duodenal,  superior 
mesenteric,  and  splenic  glands. 

The  function  of  the  pancreas,  aside  from  an  internal  secretion  effecting 
carbohydrate  metabolism,  is  the  secretion  of  from  half  a  pint  to  a  pint 
of  alkaline  juice  daily,  the  quantity  varying  in  proportion  to  that  of  the 
acid  chyme  passed  from  the  stomach.  The  acid  chyme  forms  secretin 
from  the  duodenal  epithelium,  which  in  turn  excites  the  pancreatic 
cells  to  activity. 

The  pancreatic  fluid  is  the  universal  digestant  except  for  connective 
tissue,  acting  with  vigor  upon  fats,  particularly  when  the  latter  are  mixed 
with  bile  and  hydrochloric  acid.  Its  proteolytic  ferment,  trypsinogen, 
is  not  activated  into  trypsin  until  it  reaches  the  duodenum  and  becomes 
mingled  with  enterokinase.  Its  diastatic  ferment  is  not  observed  in  the 
first  few  months  of  life. 

Affections  of  the  pancreas  are  characterized  by  pain,  tumor,  tender- 
ness, interference  with  function,  and  metabolism. 

Pain  in  acute  pancreatitis  is  shocking  in  severity,  is  often  attended 
with  pronounced  dyspnea,  and  is  usually  placed  in  the  epigastric  region. 
The  pain  of  chronic  pancreatitis  is  at  times  recurrent  and  severe,  or 
may  be  absent.  Any  rapid  growth  or  infiltration  or  arteriosclerosis 
may  occasion  paroxysms  of  agonizing  pain.  A  backward  and  upward 
radiation  of  pancreatic  pain  has  frequently  been  noted;  exceptionally 
it  has  been  downward  to  the  right  iliac  region  or  even  along  the  course 
of  the  sciatic  nerves.  The  epigastric  tenderness  is  extreme  in  acute 
cases,  and  is  usually  accompanied  by  the  rigidity  of  peritonitis.  In 
chronic  infiammations  midline  tenderness  on  deep  pressure  is  usual. 


THE  PANCREAS  525 

Robson  states  that  in  thin  persons  with  relaxed  abdominal  walls, 
and  especially  in  those  with  ptosed  stomachs,  the  body  of  the  normal 
pancreas  can  be  readily  defined  by  palpation  in  the  epigastric  region, 
and  that  in  both  acute  and  chronic  inflammation  a  distinct  swelling 
can  often  be  felt,  giving  a  communicated,  non-expansile  pulsation 
and  slight  respiratory  movement.  The  head  of  the  gland  is  so  deeply 
placed  that  the  enlargement  must  be  great  before  it  can  be  detected 
by  palpation. 

Interference  with  function  and  metabolism  is  most  characteristically 
marked  by  large,  foul,  dirty  white,  acid,  fatty  stools,  containing  often 
undigested  muscle  fibers.  Such  stools  are  distinctly  altered  for  the 
better  by  administration  of  pancreatic  emulsion  by  the  mouth. 

The  neutral  fat  is  much  in  excess  of  the  combined  fatty  acids.  In 
steatoma  of  biliary  origin  the  quantities  are  more  nearly  equal,  the 
combined  fatty  acids  being  somewhat  in  excess. 

Distaste  for  food,  particularly  for  fats  and  meats,  the  symptoms  of  pro- 
nounced and  inveterate  indigestion,  loss  of  weight,  rapid  in  the  case 
of  neoplasm,  usually  marked  anemia,  oxalates,  acetone,  and  diacetic  acid 
in  the  urine,  in  inflammatory  cases  the  pancreatic  reaction  (Cammidge), 
a  tendency  toward  spontaneous  hemorrhage  or  bleeding  long  continued 
from  slight  wounds,  occasionally  glycosuria.  These  are  symptoms  which 
when  grouped  strongly  suggest  extensive  involvement  of  the  pancreas. 

Growths  of  the  pancreas  occlude,  either  by  their  mechanical  bulk 
or  by  infiltration,  the  common  duct,  the  portal  vein,  or  the  duodenum. 

Injuries  of  the  Pancreas. — If  extensive,  injury  is  usually  associated 
with  lesions  of  neighboring  organs  and  exhibits  no  characteristic  symp- 
toms. 

Abscess  or  cysts  may  develop  subsequently  as  a  result  of  exuda- 
tion into  the  lesser  peritoneal  cavity,  with  closure  of  the  foramen  of 
Winslow.  Post-traumatic  cysts  usually  grow  directly  from  the  pancreatic 
substance. 

Pancreatitis. — Pancreatitis,  predisposed  to  by  traumatism  or  obstruc- 
tion, congestion  or  hemorrhage,  caused  directly  by  infection  extending 
from  the  common  duct  or  duodenum,  exceptionally  carried  by  the 
blood  and  still  more  exceptionally  due  to  extension  from  the  adjacent 
organs,  may  be  acute  or  chronic.  It  is  usually  secondary  to  chole- 
lithiasis, and  primarily  or  secondarily  hemorrhagic. 

Acute  pancreatitis  is  characterized  by  the  rapid  or  sudden  onset  of 
agonizing  epigastric  pain  attended  with  shock  or  even  collapse,  dyspnea, 
cyanosis,  painful  vomiting,  and  epigastric  tenderness  and  tympany. 
The  tympany  shortly  (hours)  becomes  general,  and  there  is  often  an 
associated  slight  jaundice,  which,  if  the  affection  is  secondary  to  common 
duct  stone,  may  become  pronounced.  Referred  pain  is  to  the  back 
between  the  shoulders  or  below  the  angle  of  the  scapula  on  the  left 
side,  often  to  the  precardial  region  or  the  right  inguinal  fossa. 

Following  the  acute  onset,  if  there  be  a  reaction  from  shock,  the 
general  tenderness  and  tympany,  muscular  rigidity,  feeble  or  absent 
peristalsis^    constipation^    and    reciirring    vomiting    indicate    a    diffuse 


526         '  THE  ABDOMEN 

peritoneal  irritation.  The  affection  is  commonest  in  fat  men  with  a 
previous  history  of  chronic  indigestion,  the  latter  doubtless  secondary 
to  an  unsuspected  chronic  inflammatory  condition  of  the  pancreas. 

Acute  pancreatitis  may  occur  in  the  course  of  mumps;  marked  by 
vomiting  and  epigastric  pain  and  sometimes  definite  tumor.  This 
form  of  pancreatitis  is  less  violent  in  onset  than  the  hemorrhagic  type, 
the  symptoms  are  transitory  and  the  prognosis  is  good. 

The  framing  of  a  prompt  diagnosis  is  usually  based  upon  the  shocking 
severity  of  onset,  the  high  midline  pain,  tenderness  and  tympany, 
pain  radiation  backward  and  to  the  left,  and  the  finding  of  areas  of 
fat  necrosis  at  exploratory  section.  The  latter  have  been  found  in  the 
absence  of  pancreatic  involvement  (Fawcett). 

Later  (hours,  days),  the  symptoms  of  hyperacute  diffuse  peritonitis 
which  usually  follow  gastric  or  duodenal  perforation  are  wanting,  though 
the  belly  is  generally  swollen,  tender,  and  moderately  rigid,  and  peri- 
stalsis is  feeble.  The  feces  contain  an  excess  of  fat  and  the  urine  gives, 
according  to  Robson  and  Cammidge,  the  pancreatic  reaction  which  they 
regard  as  diagnostic.     Sugar  in  the  urine  is  exceptional. 

The  pain  of  biliary  colic  has  usually  right  radiations,  and  the  tender- 
ness is  placed  to  the  right  of  the  median  line.  Since  the  two  conditions 
are  often  associated,  a  differentiation  may  be  impossible. 

Abscess  of  the  Pancreas. — Abscess  of  the  pancreas,  usually  secondary 
to  gallstones  and  cholangitis,  may  have  an  onset  suggesting  hemorrhagic 
pancreatitis,  with  symptoms  less  marked,  particularly  those  incident 
to  shock  or  collapse.  Tenderness  over  the  pancreas,  absence  of  marked 
general  tympany  and  diffuse  peritoneal  irritation,  the  detection  of  tumor, 
constitutional  symptoms  of  infection,  rapid  loss  of  weight  and  the 
evidences  of  pancreatic  involvement  shown  by  examination  of  the  urine 
and  the  stools  will  be  elicited.  The  recurring  paroxysms  of  pain  and 
vomiting  closely  simulate  those  due  to  gallstone  with  which  this  con- 
dition is  often  associated. 

Catarrhal  Pancreatitis. — Under  this  caption,  Robson  and  Cammidge 
describe  an  affection  which  they  believe  a  cause  of  acute  and  chronic 
catarrhal  jaundice  of  non-calculus  origin,  the  obstruction  to  the  com- 
mon duct  being  not  within  its  lumen  but  due  to  pressure  of  the  swollen 
pancreatic  head.  They  state  that  catarrh  of  the  pancreas  can  be  usually 
verified  by  digestive  and  metabolic  signs  and  by  swelling  of  the  gland, 
which  can,  in  some  cases,  be  recognized  by  palpation  through  the 
abdominal  wall,  but  in  others  only  by  manipulation  of  the  pancreas 
through  the  open  abdomen. 

Suppurative  Catarrh. — Suppurative  catarrh  is  a  term  employed  by 
Robson  to  designate  a  pancreatic  condition  similar  to  suppurative 
cholangitis,  with  which  it  is  usually  associated.  The  symptoms  are 
essentially  septic,  and  the  diagnosis  of  pancreatic  involvement  is 
apparently  dependent  upon  the  presence  of  the  pancreatic  reaction 
in  the  urine. 

Chronic  Pancreatitis. — Chronic  pancreatitis,  usually  incident  to  long- 
standing obstruction,  associated  with  catarrhal  inflammation,  hence  a 


THE  PANCREAS  527 

common  accompaniment  of  common  duct  stone,  but  occurring  in  the 
absence  of  this,  is  characterized  by  progressive  wasting  (months,  years), 
inveterate  gastric  indigestion,  tenderness  on  midline  on  deep  pressure, 
the  tumor  lying  behind  the  stomach  and  carrying  aortic  pulsation,  pain 
paroxysms  with  left  posterior  radiations,  persistent  and  steadily  deepen- 
ing jaundice  in  the  late  stages,  and,  when  the  common  duct  passes 
through  the  hardened  pancreatic  head  and  the  gall-bladder  has  not 
been  previously  diseased,  painless  enlargement  of  this  viscus. 

The  laboratory  examination  should  show  pancreatic  reaction,  oxa- 
luria,  and,  in  the  late  stages,  an  excess  of  neutral  fat  and  often  free  fat 
globules  in  the  large  pale,  offensive  stools. 

The  distinction  from  cancer  of  the  pancreas  may  be  impossible  even 
at  operation,  though  the  usual  painless  onset,  comparative  rapidity  in 
progress  (months),  age  incidence  (over  forty),  completeness  of  obstruc- 
tion, ascites,  hemorrhoids,  and  tendency  to  bleeding  are  characteristic 
of  cancer.  Pancreatic  reaction  is  usually  absent  in  this  latter  condition, 
unless  there  be  an  accompanying  inflammation. 

Pancreatic  sclerosis  associated  with  a  similar  condition  of  the  liver, 
incident  to  S3^hilis  and  tuberculosis,  and  as  a  consequence  of  arterio- 
sclerosis, is  observed. 

Pancreatic  Calculus. — Pancreatic  calculus  (rare)  is  distinguished  by 
the  symptoms  and  the  urinary  and  fecal  findings  of  subacute  pancrea- 
titis. Recurring  paroxysms  of  vomiting  and  severe  pain  with  posterior 
or  left  radiation  are  recorded.  The  diagnosis  is  based  upon  a;-ray  exami- 
nation, which  shows  these  stones,  since  they  are  made  up  of  lime  salts, 
particularly  the  carbonate.  Jaundice  will  develop  if  the  stone  impinge 
upon  the  common  duct  or  be  lodged  in  the  ampulla  of  Vater. 

Pancreatic  Cysts. — Pancreatic  cysts,  frequently  following  trauma  by 
months  or  years,  and  usually  attended  with  pain,  tenderness,  and  gastric 
indigestion  with  recurrent  exacerbations,  are  marked  by  the  formation 
of  a  tense  rounded  tumor,  the  deep  origin  of  which  is  demonstrated 
by  inflation  of  the  stomach  or  colon,  or  both.  The  tumor  is  slightly 
movable,  may  extend  forward  above  or  below  the  stomach,  behind  or 
even  below  the  colon,  and  may  cause  obstructive  symptoms  from 
mechanical  pressure,  and  gives  in  the  urine  the  pancreatic  reaction 
(Robson).  Except  it  reach  huge  size  it  has  little  tendency  to  present 
in  the  flanks. 

The  diagnosis  of  the  pancreatic  origin  of  such  cysts  is,  even  at 
operation,  not  always  possible,  though  the  presence  of  the  pancreatic 
ferments,  other  than  the  diastatic,  in  the  evacuated  fluid  may  be 
regarded  as  positive  evidence.  These  ferments  are  usually  absent. 
Characteristic  alteration  in  the  urine  and  feces  and  jaundice  will  depend 
upon  the  amount  of  destruction  of  pancreatic  tissue  and  the  pressure 
effects  of  the  tumor  on  the  main  ducts. 

Cancer  of  the  Pancreas.^ — Pancreatic  cancer,  usually  of  the  scirrhous 
type,  and  occurring  after  the  fortieth  year,  is  characterized  by  rapid 
(months)  loss  of  weight  and  strength,  progressive  anemia,  and,  if  the 
head  of  the  gland  is  affected,  painless  jaundice  with  swollen  liver  and 


528  THE  ABDOMEN 

non-sensitive,  enlarged  gall-bladder;  large,  fatty,  pale,  offensive  stools, 
with  excess  of  neutral  fat  over  combined  fatty  acids,  and  absence  of 
stercobilin ;  often  edema  of  the  feet  and  ascites,  tendency  to  hemorrhage, 
and  early  fatal  termination.  The  tumor,  if  felt,  is  fixed,  hard,  deep, 
and  conveys  aortic  pulsation.  The  pancreatic  reaction  is  usually 
absent,  unless  there  be  an  associated  pancreatitis.  Extension  to  the 
liver  and  to  the  stomach  is  common. 

When  the  body  of  the  gland  is  primarily  involved,  the  tumor  can 
often  be  readily  palpated,  its  postgastric  position  being  established 
by  gastric  inflation.  At  times  the  pain  incident  to  pancreatic  cancer 
is  harassingly  severe,  with  paroxysms  of  intensity  associated  with 
vomiting  which  suggest  gallstones.  When  the  body  of  the  gland  is 
involved,  the  referred  pain  is  behind  and  to  the  left. 

From  chronic  sclerosing  pancreatitis  the  rapid  course  of  cancer  is 
diagnostic,  also  in  the  former  position  the  pancreatic  reaction  in  the 
urine  is  always  present,  nor  is  the  absence  of  bile  and  pancreatic  juice 
in  the  intestinal  contents  ever  as  complete.  Even  at  operation,  how- 
ever, it  may  be  impossible  to  distinguish  between  these  two  affections, 
the  diagnosis  then  depending  upon  the  result  of  conservative  operation 
or  autopsy. 

From  syphilitic  infiltration  the  diagnosis  must  depend  upon  the 
result  of  medicinal  treatment  suggested  by  the  history. 

Since  by  its  mechanical  pressure  pancreatic  cancer  may  produce 
symptoms  of  pyloric  stenosis,  the  distinction  from  cancer  of  the  stomach 
may  be  difficult ;  the  stools,  however,  in  cancer  primarily  pyloric  do  not 
exhibit  the  characteristics  of  those  devoid  of  pancreatic  secretion,  and 
the  vomitus  of  the  stomach  lesion  is  usually  characteristic,  though  in 
either  case  free  hydrochloric  acid  is  likely  to  be  absent. 


THE  SPLEEN. 

The  spleen  is  a  ductless  gland,  averaging  5  inches  in  length,  3  in 
width,  1^  in  thickness,  and  7  ounces  in  weight.  It  lies  in  the  posterior 
part  of  the  upper  left  side  of  the  abdomen  between  the  fundus  of  the 
stomach  in  front  and  to  the  right  and  the  arch  of  the  diaphragm  behind; 
it  extends  from  the  upper  border  of  the  ninth  to  the  lower  border  of  the 
eleventh  rib,  and  its  long  axis  corresponds  to  the  back  part  of  the  tenth 
rib.  It  is  limited  in  front  by  the  midaxillary  line  and  posteriorly  it 
reaches  to  within  1^  inches  of  the  spine.  Its  sharp  anterior  border  is 
distinctly  'notched,  forming  a  characteristic  feature  when  it  can  be 
palpated. 

The  organ  is  almost  completely  surrounded  by  peritoneum,  and  is 
held  in  place  by  the  phrenosplenic  ligament  which  connects  it  to 
the  left  crus  of  the  diaphragm,  and  by  the  colon,  which  is  held 
up  by  the  phrenocolic  ligament  which  forms  a  pocket-like  support. 
Through  the  gastrosplenic  ligament  connecting  this  organ  with  the 
stomach,  but  affording  no  support  to  it,  pass  the   vessels  which  are 


THE  SPLEEN  529 

extremely  large,  entering  the  spleen  on  its  anterior  surface  at  the  hilus. 
The  splenic  artery,  which  also  supplies  branches  to  the  pancreas  and 
the  stomach,  breaks  up  into  about  half  a  dozen  branches  about  an 
inch  before  it  enters  the  spleen.  The  splenic  vein  unites  with  the 
superior  mesenteric  to  form  the  portal  vein. 

The  nerve  supply  is  from  the  solar  plexus,  and  from  the  right  pneumo- 
gastric. 

The  spleen  is  brittle,  highly  vascular,  and  fairly  mobile.  When 
normal  it  cannot  be  palpated,  nor  can  it  be  satisfactorily  percussed. 

The  spleen  of  infants  is  relatively  large,  and  in  them  can  often  be  felt 
when  normal.  To  palpate  the  spleen,  the  finger  tips  are, pressed  firmly 
just  in  front  of  the  tips  of  the  eleventh  and  twelfth  ribs  and  the  patient 
is  instructed  to  inspire  deeply.  During  this  manipulation  the  abdominal 
muscles  must  be  relaxed.  In  case  of  any  considerable  enlargement,  the 
anterior  border  and  the  lower  anterior  angle  of  the  spleen  can  readily 
be  felt. 

Percussion  dulness  can  be  detected  only  in  case  the  spleen  is  decidedly 
enlarged. 

The  function  of  the  organ  remains  unknown,  but  it  is  supposed  to 
both  produce  and  destroy  red  blood  cells.  It  is  not  essential  to  life 
or  health. 

The  diagnosis  of  surgical  aflPections  of  the  spleen  is  based  upon  enlarge- 
ment or  displacement;  usually  both. 

Enlargement  is  commonly  an  expression  of  systemic  infection,  blood 
dyscrasia,  localization  of  infection  or  neoplasm. 

Enlargements  due  to  systemic  infection  and  blood  dyscrasia  are 
characterized  by  preservation  of  the  splenic  coiiformation,  particularly 
of  the  notch.  There  is  a  projection  beneath  the  left  costal  margin  of  a 
superficial  mass,  with  no  intestine  in  front  of  it,  exhibiting  respiratory 
movement,  and,  when  comparatively  small  and  not  fixed,  easily  slipping 
back  into  its  usual  position. 

The  lower  part  of  the  diaphragm,  as  it  bulges  forward  on  deep  inspira- 
tion, has  been  mistaken  for  the  spleen. 

Anomalies. — Absence,  imperfect  development,  or  supernumerary 
spleens  give  rise  to  no  symptoms.  The  diagnosis  can  be  made  only 
by  incision. 

Movable,  or  wandering,  spleen,  an  affection  of  adults  and  rare,  except- 
ing where  the  spleen  is  enlarged  and  the  belly  wall  lax,  is  characterized 
by  the  presence  of  a  tumor  corresponding  in  outline  with  the  spleen, 
extremely  mobile,  superficially  placed,  and  readily  reduced  to  the  normal 
position  of  this  organ.  When  a  wandering  spleen  becomes  fixed  in  a 
faulty  position,  diagnosis  may  be  suggested  by  percussion  resonance 
in  the  normal  position  of  the  spleen,  but  usually  it  is  made  only  by 
operation. 

When  a  wandering  spleen  becomes  twisted  on  its  pedicle,  the  symp- 
toms are  similar  to  those  of  perforative  peritonitis,  that  is,  sudden, 
severe  pain,  vomiting,  and  shock.  Diagnosis  is  based  upon  the  history 
of  a  wandering  spleen,  if  this  be  obtainable,  and  by  the  detection  of 
34 


530  THE  ABDOMEN 

a  hard,  tender  mass.  If  rigidity  and  tympany  obscure  this  tumor, 
diagnosis  may  not  be  made  until  an  exploratory  operation  reveals  the 
cause  of  the  symptoms.  As  a  complication  of  this  condition,  profuse 
bleeding  may  occur.  When  the  vascular  obstruction  is  not  complete, 
the  symptoms,  pain,  tenderness,  and  tumor  are  more  distinctly  char- 
acteristic. 

Traumatism. — Rupture  .^ — Rupture  of  the  spleen,  except  in  associa- 
tion with  other  extensive  visceral  lesions,  is  rare  when  the  organ  is 
healthy.  When  it  is  enlarged,  this  accident  is  not  uncommon,  even 
from  comparatively  trifling  violence  because  of  its  friability.  Rupture 
has  been  known  to  result  from  muscular  contraction. 

The  diagnosis  is  difficult  and  not  often  made  except  at  operation  or 
necropsy.  It  would  be  aided  by  previous  knowledge  of  enlargement  of 
the  spleen  as  well  as  by  inquiry  into  the  nature  of  the  accident.  The 
symptoms  are,  generally  speaking,  those  of  serious  intra-abdominal  injury. 
Most  subjects  suffer  severe  hemorrhage,  which  proves  fatal,  as  a  rule, 
within  an  hour.  The  abdomen  is  rigid,  and  percussion  reveals  fluid  blood 
within  its  cavity.  However,  on  account  of  the  formation  of  large  clots 
in  the  region  of  the  spleen,  the  left  side  continues  to  give  a  dull  note 
even  when  the  patient  is  put  on  the  right  side;  the  right  side,  however, 
becomes  resonant  when  the  patient  is  put  on  the  left  side.  This  is 
known  as  Ballance's  sign,  and  is  pathognomonic  of  rupture  of  the 
spleen  (Moynihan).  There  is  a  continuous  severe  pain  over  the 
splenic  area. 

Wounds. — Wounds  of  the  spleen  are  diagnosticated  by  the  character 
of  the  wound,  by  the  signs  of  internal  bleeding,  and  by  exploratory 
operation. 

Hypertrophy. — Hypertrophy  of  the  spleen  has  been  observed  as  an 
idiopathic  affection.  Diagnosis  is  based  upon  the  absence  of  other 
causes  of  splenic  enlargement,  nor  is  the  affection  of  surgical  interest 
unless  it  be  associated  with  displacement,  torsion,  or  other  accident. 

Congestion. — Congestion  causes  enlargement,  often  distinctly  palp- 
able, in  the  course  of  affections  of  the  lungs,  liver,  and  heart.  Diagnosis 
is  based  upon  the  adequacy  of  the  primary  condition  to  produce  such 
condition.  Aortic  insufficiency  complicated  by  an  acute  infectious 
disease  may  be  accompanied  by  a  pulsating  splenic  enlargement. 

Inflammations. — Splenitis.— -Splenitis  is  a  complication  of  infec- 
tion, particularly  malaria  and  typhoid  fever.  It  is  characterized  by 
enlargement  which  is  a  phase  of  the  systemic  disease.  The  affection 
is  usually  transitory  but  may  become  chronic,  particularly  in  the  course 
of  malaria.  It  is  of  importance  when  it  is  complicated  by  rupture, 
displacement,  or  torsion.  In  the  case  of  syphilis  there  is  often  peri- 
splenitis accompanied  by  tenderness,  pain,  slight  rigidity,  and  ultimately 
contractions,  adhesions,  and  deformity. 

Acute  Suppurative  Infection  of  the  Spleen. — This  is  a  rare  affection, 
usually  secondary  to  suppuration  elsewhere  or  to  traumatism,  or  ty- 
phoidal  or  malarial  infection.  Pain,  tenderness  and  tumor,  with  local 
peritonitis  and  the  systemic  symptoms  of  infection,  are  the  dominant 


THE  SPLEEN  531 

symptoms.  Splenic  abscess  usually  opens  into  the  general  peritoneal 
cavity  or  the  colon  or  kidney.  It  may  burrow  through  the  phreno- 
splenic  ligament  to  the  cutaneous  surface  or  into  the  pleural  cavity. 

Syphilitic  Enlargement  of  the  Spleen. — This  occurs  particularly  in 
infants  and  children,  and  is  the  usual  cause  of  enlargement  in  them. 
It  may  appear  as  an  acute  enlargement  in  the  early  course  of  the  disease, 
as  chronic  indurative  splenitis,  or  as  a  gumma.  In  the  latter  case  the 
tumor  is  rarely  of  sufficient  size  to  be  detected.  The  diagnosis  is  based, 
as  a  rule,  upon  the  effect  of  antisyphilitic  treatment. 

Tuberculous  Enlargement.^ — This  is  nearly  alw^ays  secondary  to  tuber- 
culosis in  other  parts  of  the  body.  The  affection  is  usually  masked  by 
other  abdominal  symptoms. 

Cysts. — Hydatid  cysts  (rare)  are  always  unilocular  in  the  spleen,  are 
usually  associated  with  manifestations  of  the  disease  elsewhere,  and  have 
rarely  been  diagnosticated  except  at  operation. 

Serous,  blood,  lymphatic,  and  dermoid  cysts  are  extremely  rare,  and 
could  be  diagnosticated  only  by  fluctuation  or  by  operation.  In  con- 
trast with  the  parasitic  cyst,  these  collections  of  fluid  develop  mainly  in 
the  lower  part  of  the  spleen,  and  hence  become  palpable  before  they 
reach  very  great  size. 

Tumors. — Tumors  are  rare.  They  are  characterized  by  irregular, 
usually  nodular  enlargement,  commonly  associated  with  pain  and 
tenderness  and  not  infrequently  creaking  due  to  perisplenitis. 

Sarcoma,  the  primary  tumor  most  frequently  observed,  is  charac- 
terized by  its  rapid  growth.  Carcinoma  is  secondary.  Extremely  rare 
tumors  are  lymphangioma,  cavernous  hemangioma,  and  fibroma. 

Splenic  Anemia,  or  Banti's  Disease. — A  distinctly  surgical  affection, 
characterized  by  an  indurated,  often  enormous,  spleen,  resulting  from 
hyperplasia  of  the  connective  tissue  and  endothelial  cells.  The  lym- 
phatic glands  are  not  involved,  nor  is  there  a  characteristic  blood  picture. 
There  is  an  associated  cirrhosis  of  the  liver,  usually  of  a  hypertrophic 
type,  secondary  to  the  splenic  enlargement.  There  is  pain  associated 
with  profound  weakness,  muscular  atrophy,  hemorrhages,  fever, 
together  with  the  usual  symptoms  of  anemia  and  later  ascites.  This 
affection  is  distinguished  from  the  splenic  enlargement  secondary  to 
hepatic  cirrhosis  by  the  much  greater  size  attained  by  the  spleen;  from 
sarcoma  by  the  slower  course  and  the  associated  liver  enlargement; 
from  chronic  malaria  by  the  absence  of  malarial  organisms  and  malarial 
history.  From  syphilis  by  failure  to  respond  to  treatment.  From  leuke- 
mia by  the  blood  findings. 

Amyloid  Degeneration. — Amyloid  degeneration  usually  incident  to 
prolonged  suppuration  and  associated  with  a  similar  condition  of  the 
liver  and  kidneys,  is  characterized  by  uniform,  indurated  enlarge- 
ment. 

Leukemic  Enlarg^ement. — This  occurs  in  the  splenomyelogenous 
variety  and  is  characterized  by  a  soft,  symmetrical  tumor,  later 
becoming  hard  and  reaching  an  enormous  size,  accompanied  by  peri- 
splenitis and  adhesions.     Diagnosis  is  based  upon  the  blood  findings. 


532  THE  ABDOMEN 

The  leukocytes  are  enormously  increased  in  number  and  many  myelo- 
cytes are  present.  There  is  marked  reduction  and  nucleation  of  red 
cells. 

The  splenic  enlargement  of  'pseudoleukemia,  or  Hodgkin's  disease,  is 
accompanied  by  tumor  of  the  lymphatic  glands  which  begins  in  the 
neck,  axilla,  or  groin.  This  in  itself  establishes  the  diagnosis.  Aside 
from  the  reduced  number  of  red  cells  and  hemoglobin,  the  blood  picture 
is  not  characteristic. 

THE  INTESTINES. 

The  jejuno-ileum,  twenty-two  feet  long,  lies  in  the  central  part  of  the 
abdominal  cavity  and  in  the  pelvis,  being  bounded  laterally  and  above 
by  the  large  intestine.  The  mesocolon  with  the  great  omentum  lies  in 
front  and  more  or  less  completely  separates  the  small  gut  from  the 
anterior  abdominal  parietes.  At  its  beginning,  where,  forming  a  sharp 
angle  with  the  terminal  portion  of  the  duodenum,  it  emerges  from 
beneath  the  transverse  mesocolon,  it  is  held  in  fixed  position  by  a  mus- 
culofibrous  band  from  the  left  diaphragmatic  crus,  the  ligament  of 
Trietz. 

The  upper  portion  of  the  jejuno-ileum  is  thicker,  larger,  more  vascular, 
darker  in  color,  and  more  abundantly  supplied  with  valvulse  conniventes 
than  is  the  lower  part  of  the  gut.  The  arterial  loops  of  the  upper  part  of 
the  bowel  are  imperfectly  developed,  long  straight  vessels  running  directly 
to  the  gut  wall  (Monks).  Passing  downward,  both  primary  and  second- 
ary loops  become  well  developed,  being  distinctly  marked  at  about  the 
fourth  foot.  Still  lower,  secondary  and  tertiary  loops  are  observed;  the 
latter  progressively  approach  closer  to  the  inner  margin  of  the  gut. 

The  parietal  mesenteric  attachment  of  the  small  gut  is  about  six  inches 
in  length,  starting  to  the  left  of  the  spinal  column  at  the  duodenojejunal 
junction  (body  of  the  second  lumbar  vertebra)  and  running  obliquely 
downward  and  to  the  right  to  a  position  in  front  of  the  sacro-iliac 
articulation.  Between  the  two  peritoneal  layers  of  this  mesentery 
course  the  vessels,  nerves,  and  lymphatics. 

The  arterial  supply  is  through  the  superior  mesenteric,  the  venous 
return  is  through  the  portal  system.  The  nerves  are  derived  from 
the  celiac  plexus  and  the  pneumogastric;  connections  of  the  latter  and 
the  sympathetic  with  the  lower  dorsal  segments,  explain  pain  irradiations 
and  muscular  rigidity  in  cases  of  intraperitoneal  affections.  The  nerve 
terminals  communicate  with  two  plexuses,  that  of  Auerbach  lying  between 
the  circular  and  longitudinal  muscle  fibers,  and  having  control  over 
motion,  and  that  of  Meissner,  passing  to  the  mucosa  and  dominating 
secretion  and  probably  absorption.  The  lymphatic  vessels,  after  passing 
through  a  series  of  mesenteric  glands,  one  or  two  hundred  in  number, 
terminate  in  the  thoracic  duct. 

The  function  of  the  small  intestine  is  essentially  that  of  absorption  of 
carbohydrates,  fats,  and  proteids,  excepting  in  its  extreme  upper  part, 
where   some  secretin  is   produced.     Its   muscular  coats  by  their  con- 


THE  INTESTINES  533 

traction  occasion  repeated  rhythmic  segmentation  (Cannon)  and  pro- 
pulsion. These  muscular  motions,  though  they  may  be  centrally 
stimulated  or  inhibited  through  the  pneumogastric  and  sympathetic 
fibers,  seem  to  be  dependent  in  the  main  upon  the  action  of  intrinsic 
ganglia. 

On  clinical  evidence,  in  case  of  obstruction  there  seems  to  be  a 
reverse  peristalsis,  by  virtue  of  which  the  intestinal  contents  are  thrown 
back  into  the  stomach,  though  in  many  cases  in  which  this  is  supposed 
to  have  taken  place  the  vomited  matter  is  in  reality  an  expression  of  an 
enormous  gastric  transudate. 

In  adults  the  ileocecal  valve  corresponds  in  its  surface  marking 
almost  to  the  position  usually  given  to  the  base  of  the  appendix,  i.  e., 
one  and  one-half  to  two  inches  from  the  anterior  superior  spine  of  the 
ileum  in  a  line  toward  the  umbilicus.  It  may  depart  greatly  from  this 
position  in  accordance  with  the  placing  of  the  cecum.  Its  entrance  into 
the  large  gut  is  at  a  right  angle  and  is  protected  by  a  valve,  the  most 
efficient  part  of  which  seems  to  be  a  loose  mucous  flap  opening  toward 
the  cecum  and  incompetent  against  sustained  back  pressure. 

The  colon,  beginning  at  the  cecum  and  ending  at  the  junction  of  the 
sigmoid  flexure  with  the  rectum  (third  sacral  vertebra),  has  about  twice 
the  diameter  at  its  beginning  as  in  the  terminal  portion  of  its  course. 
Its  capacity  up  to  six  months  of  life  is  about  a  pint;  up  to  the  second 
year,  between  two  or  three  pints;  and  in  adults,  about  a  gallon.  The 
cecum,  the  transverse  colon,  and  the  pelvic  colon  (sigmoid  flexure)  are 
freely  movable.  The  splenic  flexure  is  placed  far  back  and  high,  and 
is  suspended  by  the  phrenocolic  ligament,  which  in  turn  acts  as  a 
support  to  the  spleen. 

The  colon  is  distinguished  by  its  large  size,  its  sacculated  form,  the 
presence  of  longitudinal  bands  and  appendices  epiploicse,  and  in  the 
transverse  portion  by  the  attachment  of  the  omentum.  The  pelvic 
colon  (sigmoid  flexure)  exhibits  neither  sacculation  nor  longitudinal 
bands  and  normally  lies  in  the  pelvis.  In  the  fossa  made  by  the  failure 
of  its  mesentery  to  completely  unite  with  the  peritoneum  of  the  posterior 
wall  hernia  sometimes  takes  place. 

The  cecum,  lying  below  the  entrance  of  the  ileum  into  the  colon, 
about  two  and  one-half  inches  in  length,  often  completely  invested 
with  peritoneum,  is  the  largest  and  most  superficial  portion  of  the 
gut,  lying  in  the  right  iliac  fossa  with  its  blind  end  about  on  a  level 
with  a  line  joining  the  two  anterior  superior  spines  of  the  ileum. 
From  imperfect  descent  this  portion  of  the  gut  may  lie  much  above  this 
position.  In  shape  the  cecum  may  be  funnel-like,  the  appendix  forming 
the  small  end  of  the  funnel,  or  may  exhibit  symmetrical  or  asymmetrical 
pouches  divided  by  the  longitudinal  bands. 

The  appendix,  originating  at  the  termination  of  the  longitudinal  bands, 
usually  about  three  inches  in  length,  is  a  blind  tube  composed  of  a  large 
quantity  of  lymphoid  tissue,  exhibiting  a  tendency  to  atrophy  with  ad- 
vancing years.  It  has  a  valve-like  arrangement  (the  valve  of  Gerlach) 
at  its  colonic  opening  when  it  enters  this  viscus  at  an  angle  (Piersol).     It 


534  THE  ABDOMEN 

is  provided  with  a  mesoappendix  coming  from  the  left  side  of  the  mesen- 
tery and  from  the  cecum,  attached  for  a  variable  distance,  and,  because  of 
its  relatively  short  base,  commonly  causing  either  a  coil  or  a  twist  in  this 
oro;an.  In  women  a  second  mesenteric  fold  sometimes  extends  from  the 
broad  ligament  and  contains  a  branch  of  the  ovarian  artery. 

In  the  mesoappendix  lies  the  appendicular  artery  derived  from  the 
posterior  branch  of  the  ileocecal.  The  veins  pass  to  the  portal  system, 
the  lymphatics  to  the  mesenteric,  iliac,  and  postperitoneal  groups.  In 
the  female  the  bloodvessels  communicate  with  those  of  the  ovary.  The 
nerve  supply  is  from  the  superior  mesenteric  plexus. 

The  appendix  is  predisposed  to  disease  because  it  is  a  rudimentary 
organ  which  contains  an  excess  of  lymphoid  tissue,  is  poorly  drained, 
and  is  subject  to  twists  or  turns  which  interfere  with  blood  supply. 

The  surface  marking  of  the  root  of  the  appendix  lies  two  to  three 
inches  from  the  right  anterior  superior  spinous  process  of  the  ilium  on 
a  line  passing  directly  to  the  corresponding  bony  process  of  the  opposite 
side. 

The  function  of  the  colon  is  essentially  that  of  absorption.  Cannon 
has  shown  that  there  normally  exists  in  its  proximal  part  an  antiperistalsis, 
i.  e.,  waves  of  constriction  running  backward  from  the  cecum.  The 
contents  of  the  transverse  colon  are  almost  as  inspissated  as  those  of 
the  sigmoid. 

It  is  calculated  that  about  15  per  cent,  of  the  nutritive  material  and 
the  greater  part  of  the  fluid  of  the  bowel  contents  are  absorbed  by  the 
large  intestine.  From  the  stomach  downward  the  bacterial  richness  of 
the  gastro-intestinal  contents  increases. 

General  Symptomatology. — Surgical  affections  of  the  intestines  arp 
characterized  by  pain,  tenderness,  exaggerated,  diminished,  or  absent 
peristalsis,  the  presence  of  mucus,  blood,  or  pus  in  the  stools,  the  symp- 
toms of  acute  or  chronic  obstruction,  wasting  and  toxemia,  and  at  times 
by  palpable  tumor.  They  are  frequently  complicated  by  local  or  diffuse 
peritonitis. 

The  pain,  attributed  to  a  drag  on  the  mesentery,  since  the  intestine  has 
no  sensory  nerves,  is  usually  colicky  in  character,  exhibiting  remissions 
and  exacerbations  incident  to  distention  and  peristalsis.  It  may  be  a 
constant  and  localized  ache.  The  tenderness  is  rarely  acute,  unless  the 
peritoneum  be  involved. 

Exaggerated  peristalsis  is  a  symptom  of  acute  irritation  or  of  mechan- 
ical obstruction;  in  the  latter  case  it  is  associated  with  muscular  hyper- 
trophy if  the  obstruction  be  chronic  and  incomplete.  There  is  an 
exaggerated  peristalsis  of  psychic  origin  easily  recognized  as  such. 
Absent  peristalsis  may  be  of  central  origin;  it  is  usually  due  to  peri- 
tonitis. Mucus  in  the  stools  is  nearly  always  a  proof  of  catarrhal 
inflammation.  Blood  is  often  occult,  and  is  then  detected  only  by  careful 
chemical  examination  of  the  stools  after  a  meat-free  diet.  • 

Congenital  Anomalies.  — Transposition  and  malposition  of  the  intes- 
tines in  the  absence  of  obstructive  symptoms  cannot  be  diagnosticated 
without  operation,  except  in   the  case  of   the  descending  colon   and 


THE  INTESTINES  535 

sigmoid,  when  rectal  insufflation  or  injection  with  bismuth,  followed  by 
the  use  of  the  a,'-rays,  will  demonstrate  the  condition. 

Obstruction  developing  shortly  after  birth,  if  persistent,  is,  in  the 
absence  of  inflammatory  symptoms,  characteristic  of  narrowing  or 
occlusion.     The  diagnosis  must  be  made  by  operation. 

Opening  of  the  bowel  in  an  abnormal  position  (vagina,  urethra, 
bladder)  will  be  denoted  by  characteristic  symptoms.  Meckel's  diver- 
ticulum is  at  times  congenitally  patent  at  the  navel,  and  from  it  will  be 
discharged  fecal  matter,  and  about  the  umbilical  ring  will  be  found  the 
mucous  membrane  of  this  diverticulum  firmly  attached. 

Hernia  of  the  colon  into  the  thorax  through  a  congenital  defect,  if 
detected  in  the  absence  of  obstructive  symptoms,  would  be  characterized 
by  encroachment  upon  the  lung  capacity  varying  in  extent  at  different 
times  and  by  gurgling  and  peristaltic  sounds  preternaturally  clear  on 
direct  auscultation. 

Idiopathic  dilatation  of  the  colon  (Hirschsprung's  disease)  an  affection 
of  infancy  and  childhood,  which  involves  mainly  the  pelvic  colon  (sig- 
moid), though  the  gut  immediately  above  is  often  similarly  affected,  is 
due  to  defective  development  of  the  intestinal  walls  and  is  characterized 
by  an  obstinate  and  persistent  constipation,  which  yields  more  readily 
to  rectal  stimulation  than  to  medicine  by  the  mouth,  and  by  a  bulbous, 
tympanitic  belly  practically  filled  by  the  dilated  loop  of  gut.  The  rectal 
tube  passed  high  usually  drains  some  fluid  feces. 

The  diagnosis  is  based  upon  rectal  inflation,  and  upon  the  ic-ray 
picture  after  bismuth  injection  of  an  obstinately  constipated  child  with 
a  chronically  bulging,  tympanitic  belly. 

Ulcer. — Simple  ulcer  may  occur  in  either  the  large  or  the  small 
intestine  and  particularly  in  the  latter.  It  exhibits  raised  indurated 
edges  and  is  of  obscure  etiology,  though  doubtless  started  in  some  cases 
by  fecal  stasis.  It  has  been  noted  in  the  course  of  nephritis  and  after 
poisoning  by  mercury. 

The  symptoms  are  persistent  localized  pain,  and  tenderness  on  deep 
pressure,  intestinal  indigestion,  and  obvious  or  occult  blood  in  the  stools. 
Later,  as  a  result  of  cicatricial  contraction,  the  gurgling,  constipation, 
colicky  attacks,  exaggerated  peristalsis,  and  tympany  of  chronic  obstruc- 
tion may  develop. 

Peptic  ulcers  of  the  jejunum  following  gastrojejunostomy,  more 
common  in  men  than  in  women  (Gosset),  and  not  observed  after  opera- 
tion for  cancer,  are  characterized  by  severe  recurring  pain,  local  tender- 
ness, and  blood  in  the  stools,  vomiting  being  rare;  or  by  symptoms  of 
acute  perforative  peritonitis,  in  some  cases  occurring  without  previous 
symptoms,  in  others  preceded  by  pain  and  tenderness  and  rigidity. 

Dysenteric  ulcerations  of  surgical  import  are  characterized  by  pain, 
tenderness,  bloody  stools,  profound  systemic  depression,  and  usually  the 
finding  of  the  characteristic  ulcerations  by  proctoscopic  examination. 

Tuberculous  ulceration,  usually  secondary  to  pulmonary  consumption, 
in  its  diffuse  form  characterized  by  diarrhea,  the  stools  containing  occult 
blood,  and  at  times  by  the  symptoms  of  local  peritonitis,  is  not  a  surgical 


536  THE  ABDOMEN 

affection.  Single  or  multiple  tuberculous  ulcers,  affecting  by  preference 
the  small  intestine,  often  involving  both  the  small  and  the  large,  may 
perforate,  in  which  case  they  are  characterized  by  the  symptoms  of  acute 
perforative  peritonitis.  More  commonly  they  heal,  and,  as  the  long 
diameter  of  these  lesions  lies  at  right  angles  to  that  of  the  bowel,  they 
are  prone  to  produce  stenoses  which  may  be  single  or  multiple,  and 
characterized  by  the  symptoms  of  chronic  obstruction  (see  p.  481). 
They  usually  develop  between  the  twentieth  and  thirtieth  year  in 
persons  giving  a  tuberculous  history  or  exhibiting  signs  of  tuberculous 
lesion  elsewhere. 

Syphilitic  ulcer  is  unattended  by  symptoms  other  than  those  of  intestinal 
indigestion.  Theoretically,  persistent  occult  blood  in  the  stools,  associ- 
ated with  a  normal  rectum  and  a  history  of  syphilis,  might  suggest  the 
diagnosis.  The  resultant  stenosis  would  be  characterized  by  symptoms 
of  chronic  obstruction. 

Typhoid  ulcer  becomes  a  surgical  affection  only  when  it  perforates  or 
threatens  so  to  do. 

This  accident  commonly  occurs  in  the  third  week  of  the  disease,  though 
it  may  be  noted  at  any  period,  nor  has  it  a  relation  to  the  severity  of  the 
fever.  The  perforation  is  usually  single,  occurring  in  the  lower  part  of 
the  ileum. 

The  most  characteristic  feature  of  this  complication  is  the  sudden 
onset  of  agonizing,  shocking  pain,  usually  referred  to  the  lower  right 
abdominal  quadrant,  the  almost  immediate  development  of  a  weak, 
rapid  running  pulse,  and  a  sudden  drop  in  temperature.  Neither 
vomiting,  flank  dulness,  nor  absence  of  liver  dulness  are  of  service  in 
forming  an  early  diagnosis.  In  some  cases  there  is  a  rapid  and  marked 
increase  in  the  number  of  leukocytes.  Probable  diagnosis  is  further 
confirmed  by  the  rapid  development  of  the  tenderness,  tympany, 
rigidity,  and  regurgitant  vomiting  of  diffuse  peritonitis  (see  p.  478). 
Its  symptomatology  is  the  same  as  that  of  perforation  of  an  acutely 
infected  gall-bladder,  of  a  suppurating  mesenteric  gland  or  of  a  gan- 
grenous appendix,  each  an  occasional  complication  of  typhoid  fever. 

The  distinction  between  perforation  and  hemorrhage  is  based  upon  the 
rapid  progressively  weak  pulse  of  the  latter  condition,  unassociated  with 
the  severe  pain  of  perforation;  and  shortly  by  the  rectal  evacuation  of 
blood.  Neither  local  tenderness  nor  rigidity  is  marked.  The  reaction 
from  hemorrhage  is  usually  prompt  and  well  marked. 

From  appendicitis  the  distinction  would  be  based  upon  the  slower 
onset,  absence  of  primary  shock,  milder  local  and  general  symptoms 
and  their  stationary  character  for  a  time  (hours  or  days).  The  differ- 
ential diagnosis  has  frequently  been  made  only  by  operation. 

Cholecystitis,  a  common  complication  in  typhoid  fever,  exhibits  severe 
pain,  placed,  however,  in  the  right  hypochondriac  region,  and  often 
referred  to  the  back  and  shoulder,  associated  with  almost  immediate  and 
persistent  vomiting.  It  does  not  exhibit  the  symptoms  of  primary  shock 
and  there  can  be  demonstrated  a  tenderness,  rigidity,  sometimes  a  tumor 
in  the  region  of  the  gall-bladder. 


THE  INTESTINES  537 

Right-sided  pneumonia  and  pleurisy  are  customarily  not  attended  by 
such  marked  primal  shock.  Vomiting,  tympany,  tenderness,  and  rigidity 
may  all  be  present,  but  the  latter  two  signs,  the  ones  of  cardinal  impor- 
tance, are  more  marked  on  superficial  than  on  deep  pressure,  nor  are 
they  by  any  method  of  examination  developed  in  as  typical  a  form  as 
when  they  indicate  an  underlying  peritonitis;  respirations  are  hurried 
out  of  proportion  to  the  temperature,  and  after  a  brief  time  the  local 
signs  of  lung  involvement  can  be  elicited. 

Iliac  and  femoral  thrombosis  are  less  stormy  in  onset  and  more 
suggestive  of  appendicitis,  since  they  may  be  characterized  by  right 
iliac  pain,  tenderness,  and  rigidity.  The  primal  shock  is  wanting,  and 
there  is  an  elevation  in  temperature  rather  than  a  sudden  drop.  The 
symptoms  are  rarely  so  violent  as  to  justify  an  immediate  operation; 
as  a  rule,  they  lead  to  a  suspicion  of  deep-seated  abscess  rather  than 
acute  diffuse  peritonitis. 

Tumors  and  Infiltrations  of  the  Intestine. — Of  the  benign  tumors, 
polypoid  adenoma  is  the  commonest  form.  An  affection  of  youth,  it 
is  often  multiple,  and  is  usually  detected  only  in  the  course  of  operation 
necessitated  by  its  complications,  i.  e.,  invagination,  obstruction  by 
bulk,  or,  rarely,  hemorrhage.  Exceptionally  it  may  attain  a  size  suffi- 
ciently great  to  be  detected  by  palpation. 

Such  a  tumor  occurring  in  an  adult  cannot  be  distinguished  from 
malignant  growth  except  by  operation  unless  there  be  a  history  of  its 
long  continuance  (years)  and  slow  growth. 

Lipoma  and  Myoma. — Lipomata  and  myomata  (rare),  subserous  in 
origin  and  not  projecting  into  the  lumen  of  the  bowel,  may  reach  large 
size  without  symptoms  other  than  that  of  a  palpable  and  usually  freely 
movable  tumor. 

Diagnosis  is  suggested  by  the  slow  development  (years)  of  these 
tumors.  It  should  be  made  by  operation,  since  they  are  prone  to 
undergo  malignant  degeneration. 

Sarcoma. — Sarcoma  of  the  small  and  large  intestine  can  be  distin- 
guished as  such  only  by  operation,  often  not  until  microscopic  sections 
have  been  made.  In  general  terms  a  sarcoma  develops  in  younger 
people,  grows  more  rapidly,  invades  the  gut  more  extensively,  contracts 
adhesions  to  surrounding  structures  more  widely,  gives  metastasis  to 
the  liver  and  other  intraperitoneal  organs  more  promptly,  and  kills 
sooner  than  carcinoma.  Moreover,  in  a  fair  percentage  of  cases  it 
reaches  larger  size  before  obstructive  symptoms  develop.  A  pseudo- 
leukemic  growth  may  start  in  a  Peyer's  patch. 

Carcinoma. — Carcinoma,  rare  in  the  small  intestine,  has  for  its  seat  of 
preference,  if  the  rectum  be  excepted,  the  ileocecal  junction,  thereafter 
the  sigmoid  and  the  splenic  and  hepatic  flexures  of  the  colon. 

Glandular  epithelioma,  the  common  type,  occurs  in  middle  life  (forty 
to  sixty  years),  with  many  exceptions  to  this  rule,  and  is  slow  in  giving 
glandular  extension  or  remote  metastases.  In  the  early  stages  there  are 
no  symptoms;  exceptionally  deep-seated,  localized  pain,  and  persistent 
tenderness  and  occult  or  obvious  blood  in  the  stools. 


538  THE  ABDOMEN 

The  diagnosis  is  usually  based  upon  irregular  gaseous  distention,  con- 
stipation alternating  with  diarrhea,  recurring  colicky  pains,  persistent, 
gaseous  gurgling,  exaggerated  peristalsis,  local  tenderness,  and  the 
detection  of  a  tumor  usually  movable.  When  the  splenic  or  the  hepatic 
curvature  is  involved,  it  is  usually  impossible  to  palpate  the  tumor, 
even  though  it  be  carcinoma  of  large  size  (small  fist).  Rectal  inflation 
may  make  a  sigmoid  tumor  obvious  which  could  not  be  felt  otherwise. 
An  attack  of  acute  obstruction  is  sometimes  the  first  symptom. 

Tuberculosis  of  the  Intestine. — ^Tuberculosis  of  the  intestine  may  be 
primary  or  secondary.  In  its  secondary  form,  which  rarely  produces 
stenosis,  it  appears  as  multiple  ulcers,  their  presence  being  suggested 
by  colicky  pains,  intestinal  indigestion,  and  occult  or  obvious  blood  in 
the  stools.  The  mesenteric  glands  may  be  involved,  and  tuberculous 
peritonitis  at  times  complicates  the  condition.  The  diagnosis  is  sug- 
gested by  the  progressive  development  of  intestinal  symptoms  in  a 
person  suffering  from  pulmonary  tuberculosis. 

Tuberculosis  of  the  intestine  in  the  localized  hypertrophic  form, 
having  its  seat  of  preference  about  the  ileocecal  valve,  developing  at 
times  in  the  sigmoid,  is  usually  primary  in  the  cecum  and  extends 
along  the  ascending  colon.  The  appendix  may  be  greatly  thickened  or 
atrophied  and  obscured  by  a  connective  tissue  and  fat  outgrowth. 

The  early  symptoms  are  those  of  intestinal  dyspepsia,  i.  e.,  flatulence, 
colicky  pains,  and,  not  infrequently,  alternating  diarrhea  and  constipation. 
In  the  ulcerative  type  these  symptoms  are  referred  to  the  seat  of  involve- 
ment, usually  the  right  iliac  fossa,  and  an  inflammatory  tumor  is  associated 
with  tenderness  to  deep  pressure  and  often  muscular  rigidity.  Fistulte 
opening  externally  into  the  general  peritoneal  cavity  are  rare.  In  the 
hypertrophic  type  a  hard,  cylindrical  mass  forms,  either  preceded  or 
followed  by  symptoms  of  chronic  obstruction.  This  tumor  may  be 
movable  or  bound  down. 

The  distinction  from  carcinoma  is  based  upon  the  comparative  youth 
of  those  affected,  the  slow  course  of  the  disease  (years),  and  the  finding 
of  tubercle  bacilli  in  the  stools.  Even  at  operation  the  condition  may 
so  closely  simulate  carcinoma  that  the  distinction  can  be  made  only  by 
microscopic  examination. 

From  actinomycosis  the  distinction  must  be  made  by  bacteriological 
examination  of  either  the  discharge  or  an  excised  mass. 

The  distinction  from  chronic  appendicitis  can  be  made  only  by  opera- 
tion. 

Diverticulitis.— Acquired  diverticulitis  may  occur  in  any  part  of  the 
intestinal  tract,  including  the  vermiform  appendix.  Its  usual  seat  is 
the  sigmoid  flexure,  the  diverticula  projecting  into  the  appendices  epi- 
ploicse  or  through  the  openings  for  the  bloodvessels  at  the  mesenteric 
attachment.  Constipation  seems  a  predisposing  factor,  and  middle- 
aged  or  old  fat  men,  or  those  who  have  been  fat  (Telling),  are  especially 
subject  to  the  formation  of  diverticula.  The  diverticula  are  usually 
filled  with  feces,  often  contain  concretions,  and  may  become  inflamed, 
gangrenous,  or  perforate. 


THE  APPENDIX  539 

The  most  important  and  characteristic  resuU  of  mukiple  diverticuhtis 
is  a  chronic  proliferation  of  the  submucous  and  subserous  coats  of  the 
bowel  resulting  in  stenosis,  tumor  formation,  and  mimicry  of  carcinoma 
(Telling)  so  close  that  the  more  benign  nature  of  the  affection  may  not 
be  recognized,  either  at  operation  or  necropsy  (Moynihan).  The  gut 
exhibits  at  most  fistulse  or  abscesses,  never  a  fungating  ulcer. 

The  diagnosis  must  be  made  by  operation;  at  times  by  microscopic 
section  of  the  excised  mass. 

The  inflammatory,  suppurative,  and  adhesive  complications  are  char- 
acterized by  symptoms  precisely  like  those  of  appendicitis,  but  are 
placed  on  the  left  rather  than  on  the  right  side  of  the  belly.  A  fistu- 
lous communication  with  the  bladder  and  resultant  cystitis  is  noted  in 
10  per  cent,  of  the  recorded  cases. 

The  distinction  between  diverticulitis  and  tuberculosis  of  the  hyper- 
plastic type  must  be  made  by  microscopic  examination  of  the  excised 
gut  segment. 

Impaction  of  feces  (rare  excepting  in  its  rectal  form)  usually  occurs 
in  the  pelvic  colon  or  proximal  to  the  splenic  flexure,  and  is  character- 
ized by  constipation  alternating  with  diarrhea,  vomiting,  the  systemic 
symptoms  of  intestinal  toxemia,  and  the  formation  of  a  tumor  which 
can  be  moulded  and  changed  in  conformation  by  deep,  continued 
pressure.  This  is  essentially  an  affection  of  the  aged  excepting  in  its 
rectal  form.  The  stools  often  contain  mucus,  blood,  and  scybala.  The 
absolute  diagnosis  may  be  dependent  on  the  effect  of  repeated  high 
enemata. 

Actinomycosis. — Actinomycosis  is  characterized  by  a  preliminary 
period  of  intestinal  diarrhea  with  bloody  passages,  usually  not  painful, 
later  by  localized  pain  and  tenderness,  and  tumor  w^hich  involves  the 
parietes,  softens,  reddens,  and  changes  to  a  violet  blue  spreading  from 
the  centre  to  the  periphery,  held  by  Yolkmann  to  be  of  diagnostic  signifi- 
cance. Multiple  fistulse  ultimately  form,  healing  in  one  direction  and 
extending  in  others.  The  diagnosis  is  made  by  the  microscope  or  is 
based  upon  the  presence  of  other  foci  of  the  disease. 


THE  APPENDIX. 

The  appendix  may  be  absent  (rare).  It  is  about  three  inches  long 
but  varies  from  half  an  inch  to  nine  inches.  It  usually  lies  behind  the 
cecum,  exceptionally  extraperitoneally  and  is  coiled  by  its  mesenteric 
attachment.  Its  free  end  varies  in  position  in  accordance  w^ith  its  length 
and  the  extent  of  its  mesenteric  attachment.  It  may  be  found  as  high 
as  the  gall-bladder  or  to  the  left  of  the  midline.  A  process  of  non- 
inflammatory atrophy  and  partial  or  complete  obliteration  of  the  lumen  of 
the  appendix  is  frequently  noted. 

Though  the  appendix  is  subject  to  tuberculous  and  malignant  infiltra- 
tion, these  conditions  are  not  suspected  until  demonstrated  by  examination 
of  specimens  removed  in  the  course  of  operation  called  for  by  associated 


\ 


540  THE  ABDOMEN 

inflammation.  Malignant  tumors  have  usually  been  found  only  by 
microscopic  examination  of  the  removed  organ;  hence  from  the  diag- 
nostic point  of  view  acute  and  chronic  inflammation  of  the  appendix 
are  mainly  to  be  considered. 

Acute  Appendicitis. — Acute  appendicitis,  essentially  an  afi^ection  of 
vigorous  young  men,  common  in  childhood,  rare  in  infancy  and  old 
age,  is  characterized  by  pain,  tenderness,  rigidity,  vomiting,  fever,  and 
constipation. 

The  pain,  which  at  first  may  be  general,  umbilical,  or  epigastric, 
shortly  becomes  most  marked  in  the  right  iliac  fossa.  It  is  usually 
continuous,  with  recurring  exacerbations,  and  is  aggravated  by  coughing, 
vomiting,  deep  breathing,  or  abdominal  movements. 

Tenderness  on  palpation,  the  most  important  single  localizing  symp- 
tom, is  best  elicited  by  deep  pressure  at  McBurney's  point  made  with  the 
tips  of  two  fingers.  When  the  anterior  parietal  peritoneum  is  inflamed, 
superficial  tenderness  is  so  marked  that  deep  palpation  is  not  possible. 

Pain  and  tenderness  are  both  sometimes  referred  to  the  left  iliac 
fossa,  and  are  then  suggestive  of  the  pelvic  seat  of  the  tip  of  the  appendix. 
This  same  position  causes  frequency  of  urination  or  pain  at  the  end  of 
the  act.  If  the  ureter  be  involved,  the  pain  may  radiate  into  the  testicles 
or  penis. 

An  inflamed  appendix  lying  posteriorly  commonly  occasions  some 
rigidity  of  the  psoas  muscle  characterized  by  slight  flexion  of  the  thigh 
and  pain  in  efforts  at  extension.  Pain  is  sometimes  referred  to  the  hip- 
joint  or  down  the  posterior  inner  surface  of  the  thigh. 

Muscular  rigidity  involves  particularly  the  lower  half  of  the  right 
rectus  muscle,  usually  all  the  muscles  of  the  inguinal  region.  A  fixed 
contraction  of  a  portion  of  the  internal  oblique  or  transversalis  may 
closely  simulate  tumor. 

Nausea  and  vomiting  are  common  accompaniments,  sometimes  initi- 
ating the  attack,  usually  developing  some  hours  after  its  beginning.  Vom- 
iting is  not  likely  to  be  persistent  or  recurring  in  the  absence  of  diffuse 
general  peritonitis. 

The  bowels  are  usually  constipated.  There  is  commonly  a  preceding 
history  of  constipation,  or  of  gastro-intestinal  disturbance,  occasionally 
of  abdominal  chill,  contusion,  or  strain. 

There  is  fever,  usually  moderate,  sometimes  high,  and  leukocytosis. 
In  uncomplicated  cases  the  pulse  is  proportionate  to  the  temperature. 

Inspection  of  the  abdomen  shows  breathing  of  the  thoracic  type  of 
about  normal  frequency,  at  times  bulging  in  the  right  iliac  fossa  due  to 
muscular  contraction  or  local  distention,  and  often  moderate  general 
tympany. 

The  onset  of  symptoms  affords  no  reliable  index  as  to  the  subsequent 
course  of  the  appendicitis.  The  sudden  lessening  of  pain  and  tenderness 
may  denote  the  relief  of  tension  incident  to  gangrene  or  the  internal 
rupture  of  an  abscess.  Rupture  into  the  general  peritoneal  cavity  is 
at  times  characterized  by  an  immediate  and  shocking  aggravation  of 
pain. 


THE  APPENDIX  54I 

The  subsidence  of  the  local  symptoms,  associated  with  a  weak,  rapid 
pulse,  is  of  grave  prognostic  import. 

The  complications  of  acute  appendicitis  are:  Local  peritonitis,  with 
or  without  abscess  formation;  intestinal  obstruction;  diffuse  peritonitis; 
phlebitis,  epecially  pylephlebitis;  subphrenic  abscess;  pyelitis,  pyelo- 
nephritis, and  cystitis. 

Local  peritonitis  is  practically  an  invariable  accompaniment  of  ap- 
pendicitis, and  it  is  not  until  the  symptoms  of  this  condition  develop 
i.  e.,  fever,  tenderness,  and  rigidity,  that  a  diagnosis  can  be  made. 

Abscess  formation  is  characterized  by  a  persistence  or  aggrtu'ation  of 
the  symptoms  of  local  peritonitis  together  with  those  of  septic  absorption. 
Tenderness  becomes  more  marked  and  more  circumscribed,  rio-idity 
more  pronounced,  and  if  the  abscess  is  placed  anteriorly  or  in  the  pelvis, 
tumor  may  be  felt  either  by  external  palpation  or  rectal  examination. 

Abscess  incident  to  suppuration  of  a  postperitoneal  gland  or  of  the 
appendix  behind  the  colon  or  to  its  outer  side  occasions  tenderness  best 
elicited  by  pressure  in  the  loin.  Pelvic  abscess  usually  causes  marked 
pain  on  urination. 

i\.ppendicular  abscess  may  follow  subacute  appendicitis,  attended  by 
symptoms  so  slightly  marked  that  in  the  absence  of  a  careful  examination 
they  are  attributed  to  indigestion.  Such  an  abscess,  insidious  in  onset, 
of  slow  growth,  and  attended  by  moderate  toxic  sjonptoms,  may  closely 
simulate  carcinoma,  from  which  it  may  be  impossible  to  distinguish  it 
except  by  operation,  though  the  size  o|_the  resultant  tumor  in  the  absence 
of  obstructive  symptoms  and  the  gradual  merging  of  its  induration  with 
the  surrounding  tissues  would  suggest  inflammation  rather  than  carcinoma. 

Intestinal  obstruction,  partial  in  its  mildest  form  and  inr-ident  \r\  In^pl 
inflammatory  paresis,  is  a  usual  svmptom  of  acute  appendicitis,  and  is  \\\e- 
cause  of  the  constipation  and  local  tympany,  associated  with  demon- 
strable, but  not  exaggerated,  peristalsis. 

Exceptionally  from  inflammatory  adhesion  the  obstruction  becomes 
absolute ;  it  then  exhibits  in  addition  to  the  tympany  of  local  peritonitis 
the  colicky  pain,  the  exaggerated  peristalsis,  the  recurring  and  persistent 
vomiting,  the  absolute  constipation,  and  the  toxemia  characteristic  of 
this  condition  when  due  to  other  causes.  iVcute  or  subacute  and 
recurring  obstruction  is  usually  a  late  (weeks,  months,  years)  secpel  of 
appendicitis  and  is  then  due  to  strangulation  beneath  a  band  or  kinking 
of  the  gut  by  adhesion. 

Diffuse  peritonitis  is  the  commonest  immediate  sequel  of  appendicitis  if 
local  abscess  be  excepted.  It  exhibits  typical  symptoms  (see  p.  478),  and, 
when  well-developed,  may  entirely  obscure  its  original  cause,  the  diagnosis 
of  this  being  based  upon  the  histor}*  of  onset  and  possibly  upon  an 
intensification  of  pain  and  tenderness  in  the  right  iliac  fossa. 

Phlebitis  may  be  secondary  to  appendicitis,  as  it  is  to  other  forms 
of  infection.  It  occurs  generally  during  convalescence,  and,  when  it 
attacks  the  mesenteric  veins,  is  marked  by  diffuse  pain  and  tenderness, 
moderate  tympany,  fever,  and  leukocytosis.  In  the  case  of  the  iliac  or 
femoral  vein,  pain  and  edema  of  the  leg  and  the  detection  of  the  swollen, 


542  THE  ABDOMEN 

tender  vein  on  palpation  are  diagnostic.  When  intra-abdominal  veins 
are  involved  the  diagnosis  must  be  by  exclusion,  possibly  confirmed  by 
the  detection  of  an  inflamed  peripheral  vein. 

Pylephlebitis,  the  most  serious  manifestation  of  secondary  vein  in- 
fection, accompanied  by  suppuration  of  the  liver,  is  a  late  (weeks)  sequel 
of  acute  appendicitis,  particularly  of  the  insidious  form.  It  is  charac- 
terized by  the  symptoms  of  violent  sepsis,  and  pain,  tenderness,  and 
swelling  in  the  region  of  the  liver. 

Subphrenic  abscess,  usually  of  the  right  side,  and  due  to  peritoneal 
extension,  the  infection  exceptionally  reaching  the  diaphragmatic  region 
postperitoneally,  is  often  complicated  by  a  serous  or  purulent  pleurisy. 
The  symptoms  are  similar  to  those  of  suppurative  pylephlebitis,  but  less 
markedly  septic. 

Pleurisy,  even  in  the  absence  of  subphrenic  abscess,  is  an  occasional 
complication  of  appendicitis  as  it  is  of  other  septic  processes. 

Pyelonephritis  and  cystitis  are  caused  by  extension  of  inflammation 
or  rupture  of  an  abscess  into  the  pelvis  of  the  kidney  or  the  bladder, 
an  exceptional  ultimate  result  in  intestino-urinary  fistula. 

Septicemia  and  pyemia  with  their  various  expressions  may  be  com- 
plications of  infection  of  the  appendix. 

Chronic  Appendicitis. — Chronic  appendicitis,  usually  consequent  upon 
an  acute  or  subacute  attack,  often  developing  in  the  absence  of  a  history 
of  such,  may  be  manifested  by  recurrent  acute  attacks,  with  intervals 
of  perfect  health,  or  by  a  condition  of  chronic  invalidism,  with  some 
symptoms  referred  to  the  right  iliac  fossa  or  with  simply  those  of  a  chronic 
gastro-enteritis  with  toxic  absorption. 

Localized  pain  and  tenderness  occurring  with  exacerbations  usually 
incident  to  imprudence  in  diet  attended  by  muscular  rigidity  and  perhaps 
slight  fever  are  sufficiently  diagnostic  of  the  recurrent  or  relapsing  forms. 
The  latent  form,  characterized  mainly  by  a  mild  but  inveterate  toxemia, 
may  be  exceedingly  difficult  to  diagnosticate. 

Chronic  constipation,  flatulence,  distaste  for  food,  and  impaired 
stomach  digestion,  sometimes  diarrhea,  and  pain  which  may  be  placed 
in  any  part  of  the  abdomen  or  may  exhibit  radiations  downward  simu- 
lating sciatica,  sacro-iliac  disease,  or  coxalgia,  are  symptoms  which  may 
arise  from  many  different  conditions,  all  of  which  must  be  eliminated 
before  a  diagnosis  of  chronic  appendicitis  can  be  made.  It  is  in  this 
condition  particularly  that  the  Head  sign — i.  e.,  cutaneous  hyperalgesia 
in  the  region  immediately  overlying  the  appendix — may  be  of  service. 

A  diagnosis  formulated  on  the  basis  of  the  symptoms  of  a  chronic 
intoxication,  other  sources  of  which  have  been  eliminated  by  careful 
examination  or  treatment,  is  often  corroborated  by  operation,  but  this 
should  not  be  performed  until  the  surgeon  is  willing  to  definitely  state 
before  operation  his  belief  in  his  diagnosis. 

In  this  class  of  patients,  always  neurasthenic,  a  McBurney  point 
tender  to  deep  palpation  can  always  be  elicited,  as  could  a  tender  spot 
on  any  other  part  of  the  abdomen  toward  which  the  attention  had  been 
directed  by  repeated  and  perhaps  rough  examination. 


THE  APPENDIX  543 

The  complications  of  chronic  appendicitis  are  those  incident  to 
toxemia,  and  may  be  manifested  in  the  form  of  neurasthenia,  gastro- 
intestinal indigestion,  albuminuria,  neuralgia,  neuritis,  arthralgia, 
arthritis,  or  exanthemata. 

Of  the  abdominal  complications,  abscess,  adhesions,  and  partial  or 
complete  obstruction  and  pylephlebitis  and  hepatic  suppuration  are  those 
most  frequently  encountered. 

There  are  some  non-surgical  conditions  which  so  closely  simulate  the 
local  peritonitis  of  the  right  iliac  fossa  which  is  characteristic  of  appendi- 
citis that  mistakes  in  diagnosis  have  been  made  and  needless  operations 
have  been  performed. 

1.  The  Invasion  Enteralgia  of  Typhoid  Fever. — There  may  be  severe 
pain  in  the  right  iliac  fossa  and  pronounced  tenderness.  The  tender- 
ness is  not  sharply  localized,  the  muscular  rigidity  is  not  well  marked, 
and  the  symptoms  of  local  peritonitis  are  wanting.  The  characteristic 
prodromes  of  t\^hoid  and  particularly  the  leukopenia  and  the  slow__ 
dicrotic  pulse  are  suggestive  as  to  the  true  nature  of  the  affection.  The 
enlarged  spleen,  rose  spots,  and  the  serum  reaction  do  not  appear 
sufficiently  early  (eighth  day)  to  be  helpful  in  differential  diagnosis. 
After  the  first  week  the  symptoms  of  a  local  peritonitis  in  the  right 
iliac  fossa  may  become  pronounced  and  typical,  and  are  then  due  to 
appendicitis  or  a  deep  ulcerative  lesion  of  the  ileum  or  colon. 

2.  Referred  pain,  tenderness,  and  rigidity  secondary  to  right-sided 
pleurisy  or  pneumonia.  The  tenderness  is  superficial  and  may  be 
relieved  by  deep,  broad  pressure,  the  rigidity  is  not  well  marked,  the  local 
symptoms  are  suggestive  rather  than  diagnostic,  and  the  unduly  rapid 
breathing  should  indicate  the  diagnosis  even  before  the  physical  signs 
make  this  assured.  Observation  of  such  a  case  shows  subsidence  rather 
than  aggravation  of  the  signs  in  the  right  iliac  fossa. 

3.  Dysmenorrhea. — The  pain  and  voluntary  rigidity  simulate  appendi- 
citis mainly  to  the  enthusiastic  seeker  for  the  disease.  The  patient 
usually  makes  the  correct  diagnosis,  based  on  previous  experience  and 
knowledge  of  a  cause  for  a  more  than  usually  severe  attack. 

4.  Ileocolitis  incident  to  simple  catarrh,  ptomain  poisoning,  gout, 
uremia,  rickets,  tuberculosis,  exanthematous  skin  lesions,  and  arthritis 
(Osier)  may  exhibit  the  pain  of  appendicitis  but  without  its  localization, 
nor  are  the  other  symptoms  of  local  peritonitis  present.  The  sudden 
cessation  of  diarrhea,  the  substitution  of  fixation  for  protective  rigidity 
of  the  right  rectus  muscle,  the  increase  in  temperature  and  leukocytes 
and  an  aggravation  of  pain  and  tenderness  in  the  right  iliac  fossa  indicate 
a  local  peritonitis  usually  due  to  an  associated  appendicitis. 

5.  Inflammation  of  the  kidney  or  obstruction  of  its  ducts  exhibits  most 
marked  tenderness  on  deep  pressure  at  the  costovertebral  angle  with 
radiation  of  pain  along  the  ureter  and  to  the  external  genitals.  Exami- 
nation of  the  urine  is  usually  suggestive,  and  unmistakable  symptoms  of 
peritonitis  in  the  right  iliac  fossa  are  absent. 

6.  Inflammation  or  obstruction  of  the  gall  passages  exhibits  the  symp- 
toms of  a  local  peritonitis  in  the  gall-bladder  region,  with  evidences  of 


544  THE  ABDOMEN 

backing  of  bile  if  this  be  a  complication.  It  occurs  in  the  middle  aged 
and  Is  often  a  sequel  to  enteritis  or  t}^hoid  fever.  The  differentiation 
between  cholecystitis  and  appendicitis  may  be  impossible  with  an  inflamed 
appendix  lying  in  the  gall-bladder  region. 

7.  Inflammation  of  the  right  tube  or  ovary  causes  pain,  tenderness,  and 
rigidity  at  a  point  lower  than  that  characteristic  of  the  inflamed  appendix; 
it  is  preceded  by  vaginal  discharge  and  is  diagnosticated  by  vaginal 
examination.     The  two  conditions  may  be  combined. 

8.  Seminal  vesiculitis  at  times  causes  an  inflammation  of  the  overlying 
peritoneum,  and  is  then  characterized  by  pain,  tenderness,  and  rigidity 
located  in  the  right  iliac  fossa.  The  seat  of  greatest  tenderness  is  not 
over  McBurney's  point,  the  urine  contains  pus,  there  is  a  history  of  ure- 
thritis, and  a  rectal  examination  demonstrates  the  tender  and  enlarged 
vesicle. 

In  children  the  symptoms  of  appendicitis  are  similar  to  those  in 
the  adult.  The  affection,  however,  seems  more  prone  to  follow  slight 
traumatism,  and  the  abdominal  symptoms  of  a  pleurisy  or  pneumonia 
are  more  likely  to  lead  to  error. 

Intussusception,  strangulatecLJifiriiia,  beginning  typhoid  fever,  peri- 
nephric abscess,  pyelitis,  inflammation  of  a  retained  testicle,  and  acute 
coxitis  may  exhibit  symptoms  sufficiently  like  those  of  acute  appendicitis 
to  lead  to  a  mistaken  diagnosis. 


THE  ANUS  AND  RECTUM. 

Examination  of  the  anus  and  rectum  is  best  conducted  in  the  knee- 
chest  or  the  exaggerated  lithotomy  position,  though  the  left  lateral 
position  is  usually  satisfactory.  A  careful  inspection  of  the  perianal 
skin  is  followed  by  palpation  of  the  tissues  about  the  anus.  Thus  may 
be  detected  not  only  skin  inflammations,  fistulous  openings,  and  tumors, 
but  by  the  tenderness  and  induration,  abscesses  and  fistulous  tracts.  By 
drawing  the  buttocks  aside  and  directing  the  patient  to  strain  as  in  defe- 
cation, fissures,  hemorrhoids,  prolapse,  and  polyps  are  usually  seen. 

Digital  examination  should  always  precede  the  introduction  of  an 
instrument.  The  finger  should  be  covered  by  a  thin,  smooth  rubber  cot, 
and  should  be  lubricated  by  an  Irish-moss  preparation;  thus  is  the 
examination  made  less  painful.  When  the  anus  is  hypersensitive  the 
examination  may  be  preceded  by  a  20  per  cent,  lactate  of  eucaine  solution 
applied  by  means  of  a  cotton  swab  which  is  passed  within  the  grip  of  the 
sphincter  and  allowed  to  remain  for  five  minutes.  The  finger  is  intro- 
duced upward  and  forward  until  the  sphincter  (half  an  inch)  is  passed; 
it  is  then  turned  backward. 

Stricture,  polyp,  fissure,  ulceration,  foreign  body,  often  the  inner 
orifice  of  fistulfe,  perirectal  abscess,  infiltration,  or  tumor,  can  be  detected 
by  such  an  examination. 

The  ocular  examination  of  the  rectum  is  best  conducted  by  means  of 
straight  tubes.     For  examination  of  the  anus  when  there  is  a  sphincteric 


PLATE  XVII 

FIG     1 


Dissection  showing  the  Arrangement  of   the  Anorectal  Veins.     (Otis.) 

An  alcoholic  preparation  of  the  lower  rectum  opened  lengthwise  in  the  median  line  anteriorly,  a 
portion  of  the  mucous  membrane  and  mucocutaneous  tissue  having  been  removed  to  expose  the 
internal  and  external  hemorrhoidal  veins. 

X,  x' .  The  lowermost  plica  transversalis  recti,  one  of  a  series  of  ineffaceable  transverse  folds  that  are 
present  in  the  rectum,  with  considerable  variation  as  to  their  number  and  distinctness  in  different 
individuals.  a.  The  short  and  narrow  anastomoses  between  the  dilated  portion  of  the  internal 
hemorrhoidal  veins  above  and  the  dilated  portion  of  the  external  hemorrhoidal  veins  below,  e.  Dilated 
external  hemorrhoidal  veins,  g.  The  sulcus  or  groove  that  encircles  the  anal  orifice.  Just  above  are 
to  be  seen  the  columnte  and  lacunse  of  Morgagni.     is.  Internal  sphincter,     es.  External  sphincter. 


Longitudinal  Section  through  the  Rectal  Outlet  (Semidiagrammatic).     (Otis.) 

1.  Skin.  ■  2.  External  sphincter.  3.  Levator  ani.  4.  Longitudinal  muscular  fibers.  5.  Circular 
muscular  fibers  terminating  in  the  internal  sphincter.  6.  Internal  hemorrhoidal  veins  in  the  sub- 
mucosa.  7.  Mucous  membrane.  8.  One  or  naore  papillse  often  seen  on  the  bases  ot  the  columns. 
9.  The  anorectal  groove  which  is  produced  by  the  distention  of  the  internal  veins  just  above  it  and 
the  external  veins  just  below  it.  In  the  dead  body,  where  the  veins  are  empty,  the  groove  will  not 
be  apparent.  '  10.   Dilated  portion  of  an  external  hemorrhoidal  vein. 


THE  ANUS  AND  RECTUM  545 

contraction  of  such  obstinacy  as  to  make  gentle  digital  stretching  of  the 
anal  opening  inadequate,  Kelly's  short  speculum  and  a  headlight  answer 
best.  For  deeper  examination  a  proctoscopic  tube  carrying  an  electric 
light  is  to  be  preferred.  For  examinations  of  the  upper  part  of  the 
rectum  and  the  beginning  of  the  sigmoid,  the  distal  end  of  the  procto- 
scope should  be  provided  with  a  window  and  an  inflating  bulb,  allowing 
of  colonic  distention.  The  proctoscope  should  not  be  passed  more  deeply 
than  four  inches  unguided  by  the  eye. 

Congenital  Malformation. — The  anus  may  be  narrowed,  occluded, 
or  absent,  the  rectum  in  the  latter  case  ending  in  a  blind  pouch,  often  at 
a  considerable  distance  from  the  perineal  surface  or  communicating 
with  the  bladder,  urethra,  or  vagina,  or  provided  with  an  inadequate 
fistulous  opening  leading  to  the  surface  in  the  perineal  region.  The 
rectum  may  be  absent,  though  the  anus  is  normal. 

In  cases  of  occlusion  incident  to  absence  of  the  anus  or  rectum,  or 
both,  the  diagnostic  problem  has  to  do  with  the  determination  of  the 
thickness  of  the  occluding  tissue.  A  thin  partition  will  bulge  during 
crying  efforts  and  will  give  a  sense  of  fluctuation  to  palpation  when 
tense  and  one  of  yielding  when  relaxed. 

In  the  absence  of  these  symptoms  the  position  of  the  blind  rectal  pouch 
must  be  determined  by  perineal  dissection,  supplemented,  if  needful,  by 
colostomy  and  the  insertion  of  a  sound  into  the  descending  colon. 

Narrowing  of  the  anus  or  rectum  is  characterized  by  passage  of  ribbon- 
like feces.  Unless  extreme,  it  is  usually  undetected,  constipation  and  the 
gradual  dilatation  of  the  bowel  above  being  attributed  to  other  causes. 
The  infant  anus  should  admit,  under  gentle  pressure  and  without  undue 
stretching,  the  well-lubricated  rubber-covered  little  finger  of  the  average 
sized  man. 

The  Skin  Surrounding  the  Anus. — The  perianal  skin  is  especially 
subject  to  dermatitis,  eczema,  intertrigo,  pruritus,  folliculitis,  marginal 
abscess,  external  thrombotic  piles,  and  skin  tabs.  Also  are  found  in 
this  region  the  openings  of  perineal  abscesses  and  fistulse,  papillo- 
mata,  herpetic,  syphilitic,  tuberculous,  chancroidal,  and  epitheliomatous 
lesions. 

Dermatitis. — The  thin  pigmented  folded  skin  about  the  anal  orifice 
rich  in  hair  follicles  and  sebaceous  and  sudoriferous  glands  affords  a 
moist  and  sensitive  surface  for  the  action  of  irritants  such  as  fermenting 
discharges  from  the  anus  or  in  women  from  the  vagina. 

Burning  pain,  redness,  often  excoriation,  and  a  serous  or  seropurulent 
discharge  are  characteristic  features  associated  with  prompt  recovery  on 
removal  of  cause. 

Eczema. — Eczema  is  distinguished  from  dermatitis  mainly  by  its  per- 
sistence ;  it  is  often  associated  with  a  like  lesion  elsewhere,  particularly  on 
the  scrotum,  and,  as  is  true  of  a  simple  dermatitis,  it  exhibits  a  thickened 
cracked,  excoriated,  or  fissured  skin,  moist  with  a  chronic  discharge,  and 
attended  by  harassing  burning  and  itching,  accompanied  by  erosions  and 
a  distinct  seropurulent  discharge.  Itching  is  usually  distressingly  per- 
sistent, 
35 


546  THE  ABDOMEN 

Pruritus. — Pruritus  has  for  its  dominant  symptom  itching,  usually 
worse  at  night,  and  unattended  by  skin  changes  other  than  the  lesions  of 
scratching,  and  nearly  always  a  white,  thickened  skin  about  the  anal 
margins.  Its  usual  underlying  cause  is  an  anal  or  rectal  lesion  causing  a 
slight  discharge.  Careful  examination,  however,  often  does  not  result 
in  finding  such  a  cause. 

Folliculitis. — This  develops  about  the  anal  margins,  often  incident  to 
chafing  or  the  conditions  which  cause  dermatitis,  in  the  form  of  small  pim- 
ples or  boils,  tender  to  pressure,  healing  after  discharge,  often  persistently 
recurring,  at  times  confluent,  resembling  a  small  carbuncle.  Sometimes 
resulting  in  marginal  fistulse.  These  lesions  make  walking  and  bodily 
activity  painful,  but  do  not  interfere  with  defecation.  Their  superficial 
induration  and  acute  course  are  characteristic. 

Marginal  abscess  due  to  folliculitis,  a  broken-down  thrombus,  or  infec- 
tion from  abrasion,  is  attended  by  tenderness  and  pain,  usually  slight, 
unless  the  abscess  extend  within  the  grip  of  the  sphincter,  when  it  is 
severe,  is  greatly  aggravated  by  defecation,  and  is  associated  with  con- 
stitutional symptoms  of  infection.  Examination  shows  the  tender, 
edematous  inflammatory  infiltration.  Its  rupture  is  followed  by  a  per- 
sistent sinus  or  superficial  fistula,  which  may  have  numerous  openings; 
the  tracts,  however,  remain  just  beneath  the  skin  or  mucous  membrane. 
Their  openings  are  exposed  and  they  are  readily  followed  if  the  skin 
folds  about  the  anus  are  smoothed  out  by  stretching. 

The  onset  of  these  abscesses  is  often  so  symptomless  that  the  surgeon 
is  not  consulted  until  the  annoying  discharge  and  the  resultant  dermatitis 
make  this  seem  advisable.  Such  an  onset  is  suggestive  of  tuberculosis, 
as  is  extensive  undermining  of  the  skin. 

The  distinction  between  thrombotic  pile  and  a  marginal  abscess  would 
be  suggested  by  the  sudden  onset  of  the  former.  It  should  be  made 
absolute  by  incision  under  local  anesthesia. 

Thrombotic  external  hemorrhoids,  due  to  venous  rupture  and  blood 
extravasation,  are  characterized  by  a  sudden  perineal  ache,  often  follow- 
ing defecation,  urination,  seminal  emission,  or  muscular  strain,  and  the 
rapid  development  (within  the  hour)  of  a  hard,  tender  marginal  tumor, 
which  becomes  edematous  and  remains  tender  and  painful  for  several 
days.  If  the  tumor  lies  within  the  grip  of  the  sphincter  the  pain  is 
severe  and  persistent  and  is  greatly  aggravated  by  defecation. 

The  diagnosis,  based  upon  the  sudden  onset  of  pain,  is  made  by  direct 
examination  and  the  discovery  of  the  tender  swelling,  which,  if  it  be 
mucocutaneous,  its  usual  position,  shows  dark  blue  through  its  thin 
covering.  If  the  blood  effusion  be  too  deep  to  exhibit  characteristic 
color,  and  be  not  seen  for  one  or  two  days,  when  inflammatory  reaction 
has  developed,  the  diagnosis  from  abscess  should  be  made  by  incision. 

Inflamed  Skin  Tabs. — Because  of  a  varicose  condition  of  the  external 
hemorrhoidal  venous  plexus  and  consequent  stretching  of  the  over- 
lying skin,  its  natural  radiating  folds  are  exaggerated.  An  acute  inflam- 
mation of  one  or  more  of  these  folds  is  characterized  by  an  edematous, 
tender  swelling  and  often  some  eversion  of  the  mucous  membrane. 


THE  ANUS  AND  RECTUM  547 

These  acutely  inflamed  tabs  are  exceedingly  tender,  and  in  the  furrows 
between  them  there  are  often  fissures  or  short  superficial  fistulse.  Each 
acute  attack  is  followed  by  a  permanent  enlargement.  Even  in  the 
absence  of  a  history  of  acute  inflammatory  attacks  these  tabs  may 
become  greatly  enlarged,  forming  pendulous  fringes  about  the  anal 
aperture.  The  condition  is  usually  secondary  to  a  slight  dermatitis  due 
to  irritating  discharge. 

Fissure. — Fissure,  an  ulcer  within  the  grip  of  the  external  sphincter, 
is  an  affection  of  the  adult,  occasionally  seen  in  children.  It  is  character- 
ized by  severe  defecation  or  post-defecation  pain  and  blood-streaked  feces, 
often  by  a  few  drops  of  blood  squeezed  out  at  the  end  of  defecation. 
The  pain  may  last  for  hours,  due  in  this  case,  in  part  at  least,  to  muscular 
spasm,  and  may  be  associated  with  painful,  difficult  urination. 

The  diagnosis  is  made  by  direct  examination,  which  reveals,  first,  a 
rigid  sphincter,  next  a  sentinel  pile,  i.  e.,  a  mucous  or  mucocutaneous 
hj'pertrophied  tag  projecting  below  the  seat  of  the  ulcer,  finally  a  point  of 
sensitiveness  on  external  pressure.  Usually  on  gentle  introduction  of  the 
finger,  if  this  be  practicable,  the  induration  of  the  ulcer  is  found  in  the 
posterior  commissure  and  just  within  the  aperture.  The  ulcer  can  be 
seen  by  gently  stretching  the  buttocks  apart,  with  the  patient  in  the  left 
lateral  or  knee-chest  position.  A  satisfactory  proctoscopic  examination 
will  often  have  to  be  preceded  by  20  per  cent,  eucaine  solution  because 
of  the  associated  severe  spasm.  A  superficial  ulcer  placed  within 
the  grip  of  the  sphincter  does  not  necessarily  exhibit  the  symptoms 
of  fissure. 

Ischiorectal  Abscess. — Ischiorectal  abscess,  secondary  to  trauma  or 
rectal  or  anal  abrasion,  or  exceptionally  to  the  extension  between  the 
fibers  of  the  sphincter,  or  through  the  levator  of  a  submucous  or  a  peri- 
rectal abscess,  is  characterized  by  the  local  and  systemic  symptoms  of 
acute  inflammation,  both  well  marked.  The  pain  is  greatly  aggravated 
by  defecation.  The  tenderness  and  induration  are  elicited  by  a  finger 
passed  within  the  rectum  for  the  purpose  of  making  counterpressure 
against  external  palpation.  The  seat  of  the  tender  induration  and  its 
acute  onset  are  sufliciently  characteristic.  Later,  surface  heat,  redness, 
and  edema  develop.  Free  suppuration  usually  forms  a  burrowing  cavity 
w^hich,  if  undrained,  communicates  directly  with  the  bowel. 

Deep  pelvic  abscess,  placed  either  laterally  above  the  levator  muscle 
or  postrectally,  gives  rise  to  symptoms  of  septic  absorption.  This  condi- 
tion may  be  suspected  in  its  early  course  if  a  history  of  high  rectal  trauma 
or  ulceration  or  lesion  of  the  vesicles  and  prostate  is  present.  Digital 
examination  may  show  the  presence  of  a  boggy  swelling. 

Fistulous  Openings. — Fistulous  openings,  consequent  to  abscess  and 
often  tuberculosis,  are  the  commonest  rectal  affections  for  which  patients 
seek  relief.  They  are  characterized  by  indurations  indicating  their 
general  direction,  best  detected  by  combined  rectal  and  perineal  palpa- 
tion, and  by  the  presence  of  one  or  several  undermined  or  exuberantly 
granulating  openings  from  which  is  discharged  pus. 


548 


THE  ABDOMEN 


Fistula. — The  tract  is  usually  complete,  i.  e.,  leads  from  the  mucus 
to  the  skin  surface.  In  many  cases  it  is  external  and  incomplete,  having 
only  a  skin  opening  (blind  external  fistula).  In  a  small  percentage  of 
cases  it  is  internal  and  incomplete  (blind  internal  fistula),  having  only 
one  or  more  mucous  openings. 

The  short  superficial  marginal  fistula,  if  complete,  opens  into  one  of  the 
sinuses  of  Morgagni  or  below  it.  The  ischiorectal  fistula  usually  opens 
within  the  grip  of  the  sphincter,  usually  in  the  pocket  of  a  sinus.  It 
may  have  multiple  orifices  both  into  the  gut  and  on  the  skin  surface. 

Tuberculous  fistula  can  be  suspected  from  its  absolute  indolence, 
tendency  to  burrow  and  undermine,  failure  to  show  any  reactive  or  heal- 
ing power  under  treatment,  and,  if  the  fistula  be  complete,  the  presence 
on  the  mucous  membrane  of  a  ragged,  undermined  ulcer.  Fistula  is 
rarely  an  isolated  lesion  of  tuberculosis. 

Fig.  339 


The  raost  common  form  of  fistula  in  ano;    incident  to  marginal  abscess. 


Fistulse  originating  in  bone  disease  may  open  into  the  perineum  or  the 
rectum.  The  symptoms  of  the  major  malady  and  the  depth  and  dura- 
tion of  the  sinuses  are  characteristic. 

Urinary  fistula  may  be  perineal,  the  urine  burrowing  backward  to  the 
anus,  which  may  be  completely  surrounded  by  the  suppurating  tract. 

Diagnosis  is  formulated  by  tracing  the  perineal  induration,  by  the 
escape  of  urine  from  the  tract,  and  by  a  preceding  history  of  urethral 
obstruction.  Suppurating  bartholinitis  is  an  occasional  cause  of  peri- 
anal fistula  in  women. 

In  the  median  line,  sometimes  near  the  anus,  usually  over  the  coccyx 
or  sacrum,  lies  the  postanal  fissure  or  dimple,  which  contains  hair, 
sebaceous  matter,  and  not  infrequently  forms  a  suppurating  sinus. 

Dermoid  cysts,  developing  in  or  near  the  middle  line  over  the  coccyx 
or  the  last  sacral  vertebra,  may,  after  suppuration,  leave  a  persistent 
discharging  sinus  which  might  be  mistaken  for  one  of  rectal  origin.  The 
history  of  the  preexisting,  painless  tumor  and  the  finding  of  hair  in  the 
sinus  or  its  discharge  will  establish  the  diagnosis. 

The  course  of  fistulse  may  be  traced  by  perineal  palpation,  by  careful 
probing,  by  injection  with  peroxide  of  hydrogen  under  gentle  pressure 


THE  ANUS  AND  RECTUM  549 

and  palpation  for  crepitation  or  by  injection  with  methylene  blue  solu- 
tion, and  following  the  stained  sinuses  by  means  of  the  probe,  grooved 
director,  and  knife. 

When  the  fistulse  are  complete,  i.  e.,  have  both  skin  and  mucous 
membrane  opening,  the  inner  orifice  can  be  felt  by  palpation  and  seen 
and  probed  through  the  proctoscope.  Because  of  the  winding  course  of 
many  of  these  complete  fistulae  the  passing  of  a  probe  from  one  orifice  to 
another  may  be  impossible. 

Papilloma. — Papillomata,  or  warts,  about  the  anal  margin  are  usually 
confluent  and  may  exhibit  extensive  growth.  They  are  seen  especially 
in  women  in  association  with  similar  growths  about  the  genitalia.  They 
are  neither  indurated  nor  extensively  ulcerated  at  their  bases. 

Syphilis  of  the  Anus  and  Perianal  Region.- — Exceptionally,  this  begins 
as  a  chancre,  usually  single,  appearing  in  the  form  of  an  indolent,  indu- 
rated crack  at  the  anal  margin  rather  than  as  a  typical  rounded  sore, 
though  the  latter  may  develop. 

The  diagnosis  is  suggested  by  the  indolence  of  the  affection  and  the 
development  of  bilateral  polyganglionic  inguinal  enlargements.  It  can 
be  made  by  the  finding  of  the  spirocheta  or  the  subsequent  progress 
of  the  case. 

During  the  secondary  period  mucous  patches  are  common  about 
the  anus  and  are  prone  to  ulcerate,  forming  painful  fissures  which  from 
persistent  recurring  irritation  may  become  deep  and  destructive  ulcers 
or  may  be  complicated  by  ischiorectal  abscess.  The  condyloma  latum, 
characterized  by  flat,  raised,  round,  or  oval  patches  of  papillary  over- 
growth, is  a  not  unusual  manifestation. 

Tertiary  syphilis,  except  in  the  form  of  diffuse  myositis  paralyzing 
the  anal  sphincter,  is  rare.  The  perineum  may,  however,  be  riddled 
by  fistulse,  the  result  of  breaking  down  gummata  or  infiltrations  of  the 
rectum. 

Chancroids  of  the  anus  exhibit  the  characteristics  of  these  lesions 
on  the  genitals  in  that  the  lesion  is  acutely  inflammatory,  rapid  in 
development,  and  multiple  and  progressively  so  from  auto-inoculation 
of  skin  surfaces  lying  in  contact.  When  they  appear  in  the  fissured 
form,  from  inoculation  of  cracks  between  the  radial  skin  folds,  they  are 
likely  to  be  indolent  and  persistent. 

Chancroids  remain  superficial  and  are  complicated  by  buboes  in  the 
inguinal  region.  In  the  grip  of  the  sphincter  they  exhibit  the  symptoms 
of  fissure  except  that  they  are  more  rapid  in  development  and  are 
always  associated  with  external  lesions.  Rectal  chancroid  represents 
an  extension  from  the  anus. 

Tuberculosis. — Tuberculosis  may  appear  in  the  anal  and  perianal 
region  in  the  form  of  a  papillomatous  growth,  or  a  primary  ulcer. 
Usually  as  a  fistula,  secondary  to  perianal  or  rectal  abscess,  in  turn 
caused  by  tuberculous  folliculitis  near  or  in  the  pouches  of  Morgagni. 
The  lesions  are  characterized  by  indolence,  persistence,  slow  extension, 
moderate  infiltration,  and  association  with  tuberculous  lesion  elsewhere; 
finally,  by  the  discovery  of  the  tubercle  bacillus  in  scrapings. 


550  THE  ABDOMEN 

Malignant  tumors  of  the  anus,  anal  epitheliomata,  are  rare.  They 
may  be  either  of  the  superficial  type,  spreading  slowly  (months),  with 
typically  indurated  borders  surrounding  a  chronic  ulcer,  which  grad- 
ually deepens;  or,  when  the  malignant  infiltration  begins  in  the  follicle, 
they  may  be  characterized  by  hard,  deep,  densely  indurated  ulceration 
(months).  Infiltration  of  the  inguinal  lymphatic  glands  occurs  early. 
The  diagnosis  is  suggested  by  the  persistence  of  an  ulcerating  lesion 
which  is  not  syphilitic.  It  is  based  upon  the  microscopic  examination 
of  a  portion  of  the  growth. 

The  rectum,  by  which  is  meant  the  portion  of  the  bowel  extending 
from  the  third  sacral  vertebra  to  the  anus,  is  the  seat  of  fecal  accumula- 
tion, hence  is  especially  prone  to  inflammatory  and  ulcerating  lesions. 

Inflammatory  lesions  of  the  rectum  are  characterized  by  mucus,  pus, 
and  blood;  obstructive  lesions  by  obstinate  constipation,  often  varied 
by  spurious  diarrhea.  There  will  be  little  pain  until  the  anus  or  the 
perirectal  tissues  are  involved.  The  surgical  affections  of  the  rectum 
are  proctitis,  hemorrhoids,  prolapse,  traumatism,  foreign  body  and 
fecal  impactions,  ulceration  and  internal  fistulse,  tumors  and  stric- 
tures. 

Proctitis. — Acute  catarrhal  proctitis,  which  may  be  due  to  irritating 
fecal  matter  or  enemata,  is  characterized  by  urgent  desire  to  defecate, 
frequent  repetitions  of  the  act,  with  the  passage  of  small  quantities  at 
a  time,  failure  to  obtain  relief  therefrom,  and  a  sense  of  burning  pain 
in  the  rectum,  often  associated  with  some  difficulty  in  micturition.  The 
fecal  matter,  if  it  be  formed,  will  be  coated  with  mucus  and  perhaps  a 
little  blood.  The  attack  is  characterized  by  its  rapid  onset  and  quick 
subsidence,  usually  hours  or  days. 

Dysenteric  Proctitis. — Dysenteric  proctitis  is  characterized  by  frequent 
painful  passage  of  bloody  mucus.  The  dysenteric  lesions  are  likely 
to  become  deeply  ulcerous,  those  of  the  amebic  type  of  dysentery 
being  characteristic  because  of  their  linear  shape. 

Diphtheritic  Proctitis. — Diphtheritic  proctitis  has  been  reported  as 
a  secondary  condition. 

Gonorrheal  Proctitis. — Gonorrheal  proctitis  is  due  to  inoculation  by 
unnatural  practices,  or,  in  the  case  of  women,  by  discharges  running 
backward.  The  symptoms  are  those  of  acute  proctitis,  of  pain  and 
burning  in  the  rectal  region,  followed  by  small,  frequent,  painful  stools, 
containing  a  small  quantity  of  bloody  mucus. 

Diagnosis  is  based  on  finding  the  gonococci  in  the  discharge. 

Chronic  Proctitis. — Chronic  proctitis  is  a  common  accompaniment  of 
chronic  inflammation  of  the  large  bowel..  The  symptoms  of  the  local 
infection  are  usually  merged  in  those  of  the  major  disease,  excepting 
that  there  may  be  a  constant  mucous  discharge  from  the  relaxed 
sphincter,  associated  with  dermatitis  of  the  surrounding  thickened  skin 
and  marked  itching.  Or  the  affection  may  be  associated  with  con- 
stipation and  the  passage  of  feces  coated  with  mucus  and  blood.  The 
condition  is  commonly  complicated  by  hemorrhoids.  There  may  be 
multiple  mucous  membrane  erosions. 


THE  ANUS  AND  RECTUM  551 

Internal  Hemorrhoids. — Internal  hemorrhoids  are  capillary  or  venous. 
Capillary  hemorrhoids  exhibit  no  symptoms  other  than  bleeding,  which 
is  free,  recurring,  and  persistent;  they  may  complicate  venous  hemor- 
rhoids. The  diagnosis  is  based  upon  the  bleeding  and  upon  proctoscopic 
examination,  which  shows  one  or  more  nevous-like  patches  which  even 
the  gentle  passage  of  the  instrument  makes  bleed. 

Venous  hemorrhoids  are  evidenced  by.  the  sensation  of  a  full  rectum 
not  relieved  by  the  act  of  defecation,  bleeding,  and  prolapse,  the  latter 
occurring  at  first  only  when  the  bowels  are  opened  and  readily  reduced 
either  spontaneously  or  by  manual  pressure;  later  the  sphincter  becomes 
relaxed  and  the  prolapse  may  become  constant  or  constantly  recurring 
as  a  result  of  increased  intra-abdominal  tension. 

Often  internal  hemorrhoids  give  no  symptom.  The  diagnosis  is 
made  by  direct  examination.  When  the  piles  have  not  been  throm- 
bosed and  contain  little  connective  tissue,  they  cannot  be  felt.  If  they 
are  subject  to  prolapse  this  condition  may  be  brought  about  by  causing 
the  patient  to  defecate,  giving  him  an  enema  to  accomplish  this  end  if 
needful,  or  having  him  assume  the  position  of  defecation  and  bear 
down  as  though  accomplishing  the  act  while  the  protected  finger  which 
has  been  introduced  into  the  rectum  is  withdrawn.  A  Sims  or  short 
cylindrical  speculum  will  bring  the  hemorrhoidal  tumors  into  view. 

When  the  prolapsed  internal  hemorrhoids  are  prevented  from 
retracting  or  being  forced  back  by  the  grip  of  the  sphincter,  they  become 
greatly  swollen  and  excessively  painful. 

The  external  hemorrhoid,  which  is  a  subcutaneous  blood  clot,  is  some- 
times taken  for  an  internal  pile  strangulated  by  the  sphincter  and  violent 
painful  and  useless  efforts  are  made  to  reduce  it.  They  may  look  much 
alike,  but  there  is  no  complete  sulcus  between  the  external  pile  and 
sphincter,  and  inspection  shows  it  to  be  extrasphincteric. 

Prolapse. — Prolapse  may  involve  the  mucous  membrane  only  or  all 
the  coats  of  the  bowel. 

Mucous  membrane  prolapse,  the  commonest  form,  is  usually  observed 
in  young  children,  as  the  result  of  recurring  straining  efforts  such  as 
are  symptomatic  of  vesical  calculus  or  dysentery,  though  it  is  common 
in  the  feeble  and  aged  as  an  expression  of  muscular  relaxation.  It  is 
of  gradual  development,  and  may  involve  a  part  or  the  entire  circum- 
ference of  the  gut  which  projects  for  a  distance  of  one  or  two  inches, 
exhibiting  an  abnormally  red  and  thick  mucous  membrane  which  is 
continuous  with  the  circumanal  skin,  there  being  no  sulcus  between 
the  two. 

The  central  aperture  appears  at  the  end  of  the  projection  and  from 
it  pass  radiating  folds. 

Complete  prolapse,  which  may  contain  peritoneum  and  loops  of  small 
intestine,  forms  a  thicker,  larger  tumor,  usually  more  than  two  inches 
in  length,  curved  backward  in  the  male  and  forward  in  the  female,  and 
exhibiting  a  slit-like  orifice.  It  is  often  an  after-development  of  mucous 
prolapse,  but  exceptionally  may  develop  suddenly  as  the  result  of  a  vio- 
lent strain.     There  is  usually  little  pain  in  this  affection,  and  reduction 


552  THE  ABDOMEN 

is  easy.  Repeated  inflammation  may  make  it  irreducible.  If  the 
exposed  bowel  becomes  inflamed  and  eroded,  defecation  may  be  exceed- 
ingly painful. 

The  distinction  from  a  prolapsed  intussusception  is  based  upon  the 
finding  of  a  sulcus  between  the  projecting  mucous  membrane  and  the 
anal  margin,  the  skin  and  the  mucous  membrane  not  being  continuous. 

Trauma  of  the  Rectum. — ^Trauma  of  the  rectum,  noted  most 
frequently  in  sexual  perverts,  may  occur  from  the  rough  introduction 
of  an  injection  pipe  or,  if  there  be  preceding  disease,  from  even  the  gentle 
passage  of  rectal  bougies.  If  the  wound  be  perforating,  there  may  be 
little  or  no  immediate  bleeding  or  pain.  Rectovesical  fistula,  perirectal 
abscess,  pelvic  cellulitis,  or  peritonitis  follows  in  accordance  with  the 
depth  and  direction  of  the  perforation.  The  diagnosis  is  made  by 
direct  examination. 

Foreign  Bodies. — ^These  may  be  introduced  through  the  anus.  Usually 
they  have  been  swallowed,  finally  lodging  in  the  rectal  ampulla.  Since 
this  is  devoid  of  sensibility,  perirectal  abscess,  diffuse  cellulitis,  or  peri- 
tonitis may  develop  without  preceding  local  symptoms. 

Usually  there  are  pain,  tenesmus,  the  passage  of  mucus,  often  blood- 
stained, and  a  sense  of  fulness  in  the  rectum.  If  the  body  is  large, 
obstructive  symptoms  will  develop,  and  are  unrelieved  by  the  act  of 
defecation  which  in  itself  is  usually  painful.  Urinary  reflexes  are  at 
times  marked. 

A  small  foreign  body,  such  as  a  seed  or  fish-bone,  lodged  in  one  of 
the  crypts  of  Morgagni  may  occasion  a  constant  burning  associated  with 
distressing  sphincterismus. 

Diagnosis  is  based  upon  digital  and  proctoscopic  examination. 

Fecal  Impaction. — Impacted  masses  of  feces  may  remain  in  the  rectal 
ampulla  for  weeks  or  months,  there  being  no  symptoms  other  than  obsti- 
nate constipation  alternating  with  diarrhea,  and  mucus  and  blood  in 
the  stools.  A  persistent  or  frequently  recurring  diarrhea,  especially  if 
characterized  by  small  passages  containing  mucus  and  blood,  should 
always  suggest  rectal  examination. 

Ulceration  of  the  Rectum. — Ulceration  of  the  rectum  may  be  trau- 
matic, dysenteric,  dependent  upon  a  blind  internal  or  rectovesical  fistula, 
carcinomatous,  tuberculous,  or  syphilitic. 

Abrasions  or  erosions  accompanying  acute  irritating  catarrh  or  mild 
dysenteric  attacks  are  characterized  only  by  mucus  and  pus  in  the  stool 
and  symptoms  of  acute  proctitis.  Anal  tenderness  usually  prevents  a 
satisfactory  proctoscopic  examination,  nor  is  this  needful,  since  the 
symptoms  are  transitory. 

Traumatic  ulceration,  even  though  there  be  no  definite  history  of 
injury,  heals  promptly  or  develops  fistula.  Dysenteric  ulceration  of 
the  rectum  is  multiple  and  a  minor  feature  of  ulceration  of  the  bowel 
higher  up. 

Blind  internal  fistulse  are  particularly  marked  by  pain,  purulent, 
sometimes  blood-stained  discharge;  exacerbations  and  remissions  of 
inflammation,  the  remissions  being  accompanied  by  increased  discharge 


THE  ANUS  AND  RECTUM  553 

and  the  detection  of  indvn-ation  on  palpation,  and  by  direct  inspection 
and  probing.  Blind  internal  fistulse  may  have  two  openings,  and,  if  well 
drained,  may  be  difficult  to  find. 

Syphilitic  Ulcers. — Syphilitic  ulcers,  very  rarely  chancrous,  nearly 
always  beginning  as  infiltrations  or  gummata  of  the  tertiary  disease, 
are  characterized  by  the  painless,  s\Tnptomless  development  of  one  or 
many  punched-out  ulcers  upon  an  infiltrated  rectal  wall.  They  are 
sometimes  complicated  by  the  formation  of  gummatous  fistulse  which 
may  call  attention  to  the  rectum.  Women  are  particularly  subject  to 
tertiary  involvement  of  the  rectum,  which  begins  just  within  the  grip 
of  the  internal  sphincter. 

The  diagnosis  is  usually  not  made  until  either  abscess  or  fistula  has 
developed,  or  by  cicatricial  contracture  the  rectum  is  so  narrowed  that 
partial  obstruction  is  produced.  It  is  then  based  upon  the  history 
of  the  case,  the  insidious  onset,  the  extensive  area  of  infiltration,  or,  if 
the  affection  be  seen  earlier,  the  nodosities  of  gummata  and  the  typical 
punched-out  ulcers.  The  distinction  from  malignant  disease  should  be 
made  by  excision  and  microscopic  examination  of  a  portion  of  the 
ulcer. 

Tuberculous  Ulcers. — Tuberculous  ulcers,  found  in  the  lower  part  of 
the  rectum,  may  begin  as  inflamed  follicles  which  coalesce  and  break 
down,  leaving  undermined,  slightly  indurated  ulcers,  exhibiting  soft, 
pallid  granulations  with  bluish  borders,  and  often  a  peripheral  mucous 
membrane  infiltration  of  minute  tuberculous  nodules. 

Malignant  Ulcers. — Malignant  ulcers  are  characterized  by  extensive, 
dense,  peripheral  infiltration,  and  friable,  at  times  exuberant,  granulations. 
The  diagnosis  is  based  upon  the  presence  of  the  ulcer,  and  is  corroborated 
or  disproved  by  the  result  of  microscopic  examination  of  a  portion  of  the 
ulcer. 

Stricture  of  the  Rectum. — ^Strictures  of  the  rectum  are  consequent  to 
ulceration  and  cicatricial  contraction.  Ulcers  which  cause  strictm-es  are 
usually  malignant,  syphilitic,  or  tuberculous.  Traumatic  and  dysen- 
teric strictures  are  rare  and  usually  give  a  history  which,  associated  with 
the  absence  of  infiltration  and  the  clearly  outlined  constricting  fibroid 
tissue,  is  diagnostic. 

Stricture,  when  developed,  is  characterized  by  constipation  which 
becomes  progressively  more  obstinate,  requiring  for  its  relief  not  only 
laxatives  and  solvent  enemata,  but  violent  muscular  efforts  on  the  part 
of  the  patient,  often  assisted  by  digital  manipulations  where  the  narrow- 
ing is  low  down.  This  constipation  is  accompanied  by  dilatation  above 
the  point  of  narrowing,  often  by  an  accumulation  of  feces  which  can  be 
felt  through  the  thin  abdominal  wall,  not  infrequently  by  a  spiu-ious 
diarrhea  representing  an  overfiow  of  the  more  liquid  parts  of  the  feces 
mingled  with  mucus,  pus,  and  blood,  and  accompanied  by  the  symptoms 
of  gastro-intestinal  indigestion  and  ptomain  absorption.  The  feces  are 
broken,  but  not  necessarily  ribbon-like. 

When  the  stricture  lies  low  there  is  usually  an  associated  atony  of  the 
sphincters,  allowing  a  constant  or  intermittent  discharge  of  blood-stained 


554  THE  ABDOMEN 

mucopus.  Perineal  fistulse  are  common  complications.  When  the 
stricture  is  beyond  the  reach  of  the  finger,  the  proctoscope  should  be  used 
for  its  diagnosis.  This,  after  having  passed  the  sphincter,  is  introduced 
under  the  guidance  of  the  eye  until  the  point  of  narrowing  is  reached. 

Spasmodic  stricture,  due  to  chronic  contracture  of  the  internal  and 
external  sphincter,  can  generally  be  traced  to  some  local  inflammatory 
lesion. 

Malignant  stricture  is  characterized  by  the  deep,  friable  ulceration 
surrounded  by  its  nodular,  indurated  wall,  involving  not  more  than  two 
or  three  inches  of  the  bowel  in  its  long  axis,  usually  its  entire  circumfer- 
ence.    The  diagnosis  is  made  by  microscopic  examination. 

Syphilitic  stricture  exhibits  a  more  extensive  infiltration  often  with 
trifling  and  superficial  ulceration,  at  times  associated  with  perirectal 
abscess  and  multiple  sinuses.  It  rarely  appears  as  a  single  destructive, 
indurated  ulcer.  Such  a  stricture  may  form  in  the  absence  of  preceding 
ulceration. 

The  diagnosis  is  based  upon  the  history  of  the  case  and  the  micro- 
scopic findings.  The  therapeutic  test  is  usually  of  no  avail,  since  the 
affection,  when  seen,  has  reached  its  cicatrizing  stage. 

Tuberculous  stricture  is  rare,  since  tuberculosis  is  essentially  a  slowly 
destructive  process.  The  ulcer  is  soft,  undermined,  and  destructive, 
and  usually  complicated  by  perineal  fistulae.  The  diagnosis  is  based 
upon  the  finding  of  other  tuberculous  lesions  and  upon  microscopic 
examination. 

Narrowing  of  the  rectal  lumen  by  the  pressure  of  a  perirectal  tumor 
will  cause  obstruction  and,  from  back  pressure,  a  catarrhal  inflamma- 
tion. The  bloody,  purulent  discharge  of  ulcer  will  not  be  found,  and 
a  pelvic  tumor  of  sufiicient  size  to  occlude  the  rectum  may  be  felt. 

Tumors  of  the  Rectum. — These  may  be  benign  or  malignant. 

Polyp. — Polyp  is  the  common  benign  tumor.  It  may  have  an  adeno- 
matous, fibromatous,  myxomatous,  lipomatous,  or  lymphangiomatous 
basis. 

Polyp  is  common  in  children  and  is  single  or,  at  most,  in  small  number. 
In  the  adult  it  is  often  single,  but  at  times  is  amazingly  multiple,  the 
rectum  being  studded  with  hundreds  of  small  tumors  which  may  be 
rounded  or  pointed. 

Bleeding  and  tenesmus  are  the  only  symptoms  and  both  may  be 
absent  until  a  polyp  prolapses  sufficiently  to  be  grasped  by  the  sphincter. 
Often  a  palpable  prolapse  is  the  first  symptom.  Bleeding  from  the 
rectum  of  a  child  unattended  by  other  symptoms  is  usually  due  to  polyp. 

The  diagnosis  can  usually  be  made  by  digital  examination.  This 
may  deceive,  however,  since  the  polyp  is  readily  pushed  up  by  the  ex- 
amining finger,  and,  moreover,  if  made  up  of  mucous  tissue,  may  exhibit 
very  much  the  consistency  of  the  surrounding  rectal  wall.  By  sweeping 
the  finger  around  the  circumference  of  the  rectum  after  it  has  been  intro- 
duced as  far  as  possible  and  drawing  it  toward  the  anus  the  pedicle  may 
usually  be  felt. 

The  diagnosis  is  made  absolutely  by  a  proctoscopic  examination  which 


THE  ANUS  AND  RECTUM  555 

shows  the  mass  or  masses  usually  pallid  and  watery  in  appearance. 
The  fibrous  polyp  may  be  quite  hard, 

'The  villous  polyp  (rare)  exhibits  a  bright  red,  easily  bleeding,  warty 
surface,  distinguished  from  malignant  growth  by  the  absence  of  the 
tendency  to  deep  ulceration  and  induration  about  the  base.  It  is  an 
affection  of  the  adult. 

Fibroma,  enchondroma,  and  myoma  have  all  been  noted  as  non- 
pedicled  growths  from  the  rectal  wall  (rare). 

Cancer  of  the  Rectum. — Cancer  of  the  rectum,  commonest  in  men  past 
middle  age,  but  also  observed  in  early  life,  particularly  in  the  soft  or 
gelatinous  form,  is  usually  placed  in  the  rectal  ampulla  just  above  the 
anus.  It  forms  a  deep  friable  ulcer,  with  irregular,  nodulated,  densely 
indurated  borders,  which  ultimately  become  adherent  to  the  surround- 
ing parts.  The  infiltration  and  cicatricial  contracture  not  only  con- 
strict the  lumen  of  the  bowel,  but  lessen  it  in  length.  The  area  of 
narrowing  is  usually  not  more  than  one  to  three  inches  in  width,  except 
in  the  case  of  the  soft  or  medullary  cancer,  when  it  may  be  as  broad  as 
that  of  tertiary  syphilis. 

The  diagnosis  of  malignant  ulceration  is  suggested  by  the  habitually 
recurring  passage  of  small,  offensive  stools  containing  pus  and  blood. 
This  is  most  marked  in  the  early  morning.  At  the  time  of  first  ex- 
amination, the  ulcer  is  usually  completely  circumferential.  There 
is  obstinate  constipation,  difficulty  and  pain  in  moving  the  bowels, 
exhaustion  following  the  act,  and  rapid  deterioration  in  health.  The 
diagnosis  is  made  early  by  the  character  of  the  infiltrated  ulcer  and  the 
microscopic  examination  of  a  portion  of  it. 

Sarcoma. — Sarcoma,  an  affection  of  middle  age,  begins  as  a  sharply 
defined  submucous  nodule  which  grows  rapidly,  forming  a  soft  rounded 
tumor  with  a  clearly  defined,  non-indurated  base.  It  ultimately  ulcer- 
ates, bleeds,  and  obstructs.  It  is  diagnosticated  by  rectal  examination, 
excision,  and  microscopic  examination. 

Perirectal  Tumor.- — Perirectal  tumor  may  appear  in  the  form  of 
dermoid  cyst,  characterized  only  by  obstructive  symptoms  and  the 
detection  of  a  mass  either  behind  or  in  front  of  the  rectum,  sharply 
outlined.  It  is  found  mainly  in  women,  and  diagnosis  is  made  by  the 
finding  of  normal  uterus  and  ovaries  and  the  removal  of  the  tumor. 
From  the  anterior  surface  of  the  sacrum  and  coccyx,  lipoma,  lymph- 
angioma, and  teratoma  develop  as  congenital  tumors.  Anterior  spina 
bifida  in  the  sacral  region  may  by  projection  of  its  sac  into  the  upper 
rectum  produce  the  effect  of  a  cyst.  The  diagnosis  can  be  made  by 
deep  palpation  or  by  aspiration. 

Papillary  hypertrophies  of  the  borders  of  the  semilunar  valves, 
characterized  by  pallid,  wart-like  projections  of  their  borders,  are 
regarded  as  fertile  sources  of  all  the  neuroses.  The  same  may  be  said 
of  catarrhal  inflammation  of  crypts  or  follicles  made  by  these  valves. 
The  relation  between  cause  and  effect  in  both  these  conditions  still 
remains  to  be  demonstrated. 


CHAPTER    XVII. 

THE  LOWER  EXTREMITY. 
THE  FOOT  AND  ANKLE. 

The  skin  covering  the  dorsum  of  the  foot  is  thin,  freely  movable,  and 
overlies  a  loose  subcutaneous  fascia  in  which  are  many  veins.  The  tough 
plantar  skin,  prone  to  callosities,  is  intimately  connected  with  its  dense 
fibrofatty  subcutaneous  fascia. 

The  malleoli  constitute  the  most  conspicuous  bony  landmarks  of  the 
foot  and  ankle.  Two  fingers'  breadth  below  the  inner  malleolus  can 
be  felt  the  sustentaculum  tali,  a  finger's  breadth  in  front  of  this  bony 
point  the  head  of  the  astragalus,  an  equal  distance  farther  forward  the 
tuberosity  of  the  scaphoid,  the  most  distinct  bony  projection  of  the 
inner  border  of  the  foot. 

A  finger's  breadth  below  and  slightly  in  front  of  the  tip  of  the  external 
malleolus  the  peroneal  tubercle  or  ridge  can  be  felt,  and  three  fingers' 
breadth  in  front  of  this  the  base  of  the  fifth  metatarsus,  the  most  promi- 
nent bony  point  on  the  outer  border  of  the  foot. 

The  weight  of  the  body  is  supported  by  an  elastic  arch,  the  bases  of 
which  are  the  internal  tuberosity  of  the  calcaneum  and  the  heads  of  the 
metatarsal  bones. 

The  tibiotarsal  joint  allows  of  flexion  and  extension  through  an  angle 
of  about  75  degrees.  The  midtarsal  joints  allow  of  adduction,  abduc- 
tion, inversion,  and  eversion,  with  combinations. 

The  swelling  incident  to  joint  effusion  is  early  characterized  by 
obliteration  of  the  slight  depression  which  is  observed  to  the  inner  and 
outer  side  of  the  extensor  tendons  in  front,  and  a  similar  fulness  in  the 
space  between  the  tendo  Achillis  and  the  posterior  malleolar  surfaces. 

Deformities  of  the  Foot. — These  may  be  congenital  or  acquired. 
Such  congenital  deformities  as  acrodactylism,  syndactylism,  polydac- 
tylism,  macrodactylism,  absence  of  bony  parts,  and  talipes  varus  are 
obvious  on  inspection.  That  the  varus  of  the  newly  born,  though 
usually  acquired  incident  to  intra-uterine  pressure,  may  be  primary  is 
shown  by  the  fact  of  its  being  hereditary. 

Acquired  deformities  incident  to  pressure,  inflammation,  or  contracture, 
as  affecting  the  toes  commonly  appear  in  the  form  of  an  over-riding 
usually  of  the  second  and  fourth  toes,  troublesome  only  because  of  the 
incident  skin  maceration  and  the  formation  of  corns  at  the  points  of 
pressure. 

Hammer  Toe. — Hammer  toe,  involving  particularly  the  second  and 
the  third  toe,  is  marked  by  sharp  flexion  of  the  second  phalanx  upon  the 


THE  FOOT  AND  ANKLE 


557 


markedly  extended  first.  Bursse  underlying  the  corns  forming  over  the 
point  of  pressure  are  prone  to  suppurate  and  involve  the  neighboring 
phalangeal  joint. 

Fig.  340 


Outer  hamstring  tendon  (biceps). 


Popliteal  space. 

Line  of  joint. 

Head  of  fibula. 
Short  saphenous  vein. 


Inner  and  outer  heads  of  gastroc- 
nemius muscle. 


Peroneus  longus  and  brevis  muscles 
covering  the  fibula. 


Tendo  Achillis. 

Tip  of  external  malleolus. 

Peroneal  tubercle. 

Tuberosity  of  5th  metatarsal  bone. 


Surface  markings  of  the  leg  and  ankle.     (G.  G.  Davis.) 

Hallux  Rigidus.— Hallux  rigidus,  evidenced  by  tenderness,  swelling, 
and  fixation  of  the  metatarsophalangeal  joint  of  the  great  toe,  usually 
in  a  position  of  slight  plantar  flexion,  is  observed  in  young  people  as  a 
part  of  the  symptomatology  of  weak  foot. 

Hallux  Valgus. — Hallux  valgus,  or  outward  deviation  of  the  great  toe, 
usually  incident  to,  the  wearing  of  improperly  constructed  shoes,  excep- 
tionally due  to  gouty  or  rheumatic  joint  changes,  may  be  so  marked 
as  to  constitute  a  subluxation  outward  of  the  first  phalanx.     Over  the 


558 


THE  LOWER  EXTREMITY 

Fig.  341 


Common  deformity  incident  to  wearing  narrow  shoes. 
Fig.  342 


Bilateral  hallux  valgus  and  bilateral  bunion.      Subluxation  of  first  metatarsophalangeal 
joints.      Repeated  acute  inflammation  of  right  bunion.      (Camett.) 


THE  FOOT  AND  ANKLE 


559 


head  of  the  usually  enlarged  metatarsus  there  develops  a  tender  corn  or 
bursa.  The  latter,  called  bunion,  is  prone  to  suppuration,  which,  because 
of  the  greatly  thinned  ligaments  lying  beneath,  readily  penetrates  to  the 
joint. 


Fig.  343 


«^^^^^^^^^H  '  ^^^^^^^H 


Club  feet  secondary  to  infantile  paralysis.  Right  talipes  equinovarus.  Heel  elevated.  Foot 
inverted.  Callus  and  bursa  formation  over  surface  of  weight  bearing  along  outer  border  of 
foot.  Left  pes  planus.  Flattening  of  arch  and  lengthening  of  foot.  Relaxation  of  ligamen- 
tous structures  at  knee  shown  by  the  hyperextension.      (Willard.) 

Fig.  344 


Pes  cavus.      High  arch  and  short  foot       (Carnett.) 

Hallux  Varus. — Hallux  varus  is  the  term  applied  to  an  inward  deviation 
of  the  great  toe  more  pronounced  than  normal. 


560  THE  LOWER  EXTREMITY 

Club  Foot. — This  deformity,  exceptionally  congenital,  usually  acquired 
as  the  result  of  muscular  paralysis  and  failure  to  counteract  the  pull  of  the 
sound  muscles  and  the  drop  incident  to  the  weight  of  the  part,  appears  as 
an  equinus  (plantar  flexion),  calcaneus  (dorsal  flexion),  varus  (inversion), 
or  valgus  (eversion),  two  or  more  of  these  forms  being  commonly  com- 
bined. In  their  ultimate  development  these  deformities  are  accompanied 
by  both  malformation  and  displacement  of  the  bones  of  the  foot.  The 
congenital  form  usually  appears  as  an  equino varus. 

Flat  and  Hollow  Foot. — Flat  foot,  or  pes  planus,  often  a  natural 
formation  and  in  itself  implying  no  weakness,  and  hollow  foot,  or 
pes  cavus,  are  more  or  less  obvious  departures  from  the  ideal  mould 
which  are  readily  detected  by  inspection. 

Flat  foot  as  an  acquired  condition,  is  often,  but  by  no  means  always, 
a  feature  of  painful  foot.     The  same  may  be  said  of  the  high  arched  foot. 

Fig.  345 


Flat  feet  (bilateral  pes  planus).  Obliteration  of  arches.  Lengthening  and  eversion  of  feet. 
Prominent  scaphoids  and  internal  malleoli.  Contractures  of  toes  with  secondary  corns.  Pain- 
less.     Tires  easily  on  walking. 

AfEections  of  the  Foot  Characterized  Mainly  by  Pain. — The  pain 
incident  to  wounds,  contusions,  sprains,  joint  inflammations,  gout, 
rheumatism,  and  the  remote  effects  of  traumatism  is  usually  accom- 
panied by  other  symptoms  or  signs  of  the  underlying  cause,  and  a 
more  or  less  characteristic  history. 

Painful  Foot.^ — Painful  foot,  observed  in  lax-fibered  youths  and  young 
adults,  is  characterized  by  a  ligamentous  weakness  sufficiently  pronounced 
to  make  standing  or  walking  at  first  irksome,  later  painful.  The  foot 
is  tender  and  often  cold  and  clammy.  The  pain  is  usually  referred  to  the 
midtarsal  joint.  The  movements  of  the  foot  are  limited  by  associated 
muscular  spasm,  often  accompanied  by  cramp  of  the  foot  and  leg.  As 
the  ligaments  yield,  a  distinct  flattening  takes  place,  the  head  of  the 


THE  FOOT  AND  ANKLE  561 

astragalus  forming  an  obvious  projection  below  the  malleolus  and  in 
front  of  it. 

Pain  is  usually  more  pronounced  before  the  development  of  marked 
deformity,  the  latter  representing  an  adaptation  which  allows  of  con- 
siderable use  without  very  grave  discomfort.  The  walk  is  character- 
ized by  slightly  flexed  knees  and  short  steps,  mainly  on  the  heels  with 
the  toes  widely  turned  out,  the  shoe  soles  being  habitually  worn  down  on 
the  inner  side. 

Arteriosclerotic  Pain. — -This,  usually  observed  in  the  aged,  at  times 
in  the  young,  is  characterized  by  its  severity  and  persistence.  It  may 
precede  by  months  or  years  the  development  of  senile  gangrene.  The 
diagnosis  is  based  upon  the  associated  local  and  general  symptoms  of 
arteriosclerosis  and  the  exclusion  of  other  adequate  causes. 

Painful  Heel. — Painful  heel  is  characterized  by  tenderness  on  pressure, 
so  great  as  to  make  walking  difficult  or  even  impracticable.  It  is  often 
associated  with  bony  outgrowth;  at  times  sufficiently  pronounced  to  be 
palpable,  usually  demonstrable  only  by  the  .r-rays.  With  such  out- 
growths, or  independent  of  them,  a  chronic  bursitis  may  develop. 

Chronic  inflammation  of  the  plantar  fascia,  injury  or  abnormal  growth 
of  the  epiphysis,  or  chronic  inflammation  of  the  bursa  lying  between  the 
tendo  Achillis  and  the  calcaneum,  characterized  by  a  hardness  which 
simulates  bone,  may  be  the  underlying  cause  of  painful  heel,  the  point 
of  local  tenderness  indicating  in  each  case  the  seat  of  lesion. 

Anterior  Metatarsalgia. — Anterior  metatarsalgia,  or  Morton's  disease, 
is  a  term  applied  to  pressure  neuritis  due  to  a  distortion  of  the  anterior 
transverse  arch  incident  to  the  wearing  of  tight  or  narrow  shoes,  thus 
causing  the  heads  of  one  or  more  metatarsals  to  bear  unduly  upon  the  sole 
of  the  shoe  or  to  be  crowded  laterally  together.  The  nerve  pressure 
is  often  accentuated  by  the  growth  of  a  corn.  The  affection  is  char- 
acterized by  severe  pain  usually  beneath  the  head  of  the  fourth  meta- 
tarsal bone,  brought  on  by  walking  or  standing.  This  may  be  sudden 
and  cramp-like  in  origin,  or  may  be  preceded  by  burning  or  discomfort. 
Relief  is  afforded  by  removing  the  shoe  and  kneading  the  foot. 

Affections  of  the  Skin  of  the  Foot. — The  skin  of  the  foot  is  particu- 
larly subject  to  hyperidrosis  and  bromidrosis. 

Chilblain. — Chilblain,  usually  attributed  to  a  frostbite,  but  often  inde- 
pendent of  this,  occurring  at  any  age,  is  characterized  by  a  biu-ning  sensa- 
tion, often  accompanied  by  redness  and  tenderness;  most  pronounced 
in  cold  weather  and  aggravated  by  external  heat.  The  surface  of  the 
burning  foot  is  often  cold  and  wet. 

Er3rthema  Intertrigo. — This  appears  as  a  macerated  h^-peremic  area 
incident  to  chafing.  It  may  lead  to  ulceration,  papillary  outgrowth,  or 
eczema. 

Erjrthema  Multiforme. — Erythema  multiforme  may  in  its  nodular  form 
develop  on  the  dorsum  of  the  foot  and  simulate  the  swelling  due  to  a 
bruise  or  the  sting  of  an  insect.  It  occurs  in  the  spring  and  fall,  attacks 
young  people,  usually  exhibits  multiple  lesions,  but  is  characterized  by 
neither  the  pain  nor  tenderness  of  traumatism. 
36 


562 


THE  LOWER  EXTREMITY 


Urticaria  is  characterized  as  elsewhere  by  rapid  appearance  and  dis 
appearance  of  burning  wheals.     It  may  be  due  to  local  irritation  or 

may  be  incident  to  diet  or  medica- 
'^^^-  346  tion.    Angioneurotic  edema,  called 

giant  urticaria,  is  characterized 
by  a  red,  burning  swelling  which 
may  involve  the  whole  foot.  It 
more  commonly  appears  as  a  cir- 
cumscribed edematous  area. 

Lymphedema,  involving  the  whole 
of  the  foot,  is  usually  secondary 
to  recurring  erysipelatous  inflam- 
mation or  to  the  obstruction  of  the 
lymphatic  vessels  from  other  cause. 
It  is  characterized  by  a  brawny 
infiltration  differing  widely  from 
the  soft,  pitting  edema  incident  to 
bloodvessel  insufficiency. 

Eczema. — Eczema  of  the  feet, 
affecting  by  preference  the  sole, 
is  usually  marked  by  a  vesicular 
eruption  which  becomes  scaly  or 
crusted,  and  is  attended  by  par- 
oxysmal attacks  of  severe  itching. 
When  it  is  complicated  by  fissures 
it  may  constitute  a  distinct  dis- 
ability. It  is  usually  associated 
with  gouty  or  rheumatic  diathesis 
and  with  gastro-intestinal  disturb- 
ances. It  is  likely  to  be  symmet- 
rical and  seasonal. 

Dermatitis. — Dermatitis  is  usu- 
ally incident  to  an  infected  abra- 
sion, and  presents  the  features 
common  to  this  condition  else- 
where. It  may  be  of  such 
devitalizing  severity  as  to  cause 
gangrene  of  the  skin,  which  sub- 
sequently invades  the  deeper  tis- 
sues. This  is  particularly  noted 
in  diabetes  and  nephritis. 
Erysipelas  exhibits  its  characteristic  features.  Erysipeloid  is  also 
observed  on  the  toes. 

Diffuse  phlegmon  appears  in  its  typical  form  following  wound. 
Keratosis. — Keratosis,   appearing   in  the    form   of  a   circumscribed, 
yellowish  patch  of  cornification,  is  sometimes  the  predecessor  of  epi- 
thelioma on  the  feet. 


Keratosis  plantaris  following  chronic  eczema. 
(Hartzell.) 


THE  FOOT  AND  ANKLE  503 

Plantar  keratosis,  or  skin  thickening,  particularly  at  the  expense  of  the 
corneous  layer,  is  normal  at  points  of  pressure.  It  may  occur,  however, 
in  the  absence  of  pressure,  as  a  congenital  perversion  of  growth,  or  as  an 
expression  of  a  central  neurosis.  It  may  involve  the  whole  sole,  may 
appear  in  disseminated  patches,  or  in  the  form  of  hard,  shot-like  bodies 
which  can  be  dug  out  from  their  beds.  It  is  sometimes  associated  with 
capillary  dilatations,  particularly  in  those  subject  to  chilblains. 

Corns  and  warts  are  obvious  to  inspection. 

The  skin  sarcomas  exhibit  the  features  which  characterize  them  in 
other  parts  of  the  body. 

Ulcerating  and  Gangrenous  Skin  Lesions. — Any  of  the  skin  lesions  may 
become  ulcerative  or  gangrenous,  incident  to  virulent  infection,  con- 
tinued irritation,  or  lack  of  tissue  resistance,  singly  or  combined.  The 
deep  and  destructive  ulcers,  if  those  secondary  to  syphilitic  infiltration 
and  neoplasm  be  excepted,  begin  as  skin  lesions.  The  same  is  true  of 
gangrene  except  in  its  angiosclerotic  or  angioneurotic  type. 

Ingrowing  Toe  Nail. — This,  usually  observed  at  the  outer  side  of  the 
great  toe  nail,  appears  in  the  form  of  a  swollen,  extremely  tender  nail 
fold,  discharging  usually  from  exuberant  granulations  a  bloody  pus.  It 
may  be  the  starting  point  of  cellulitis  or  gangrene. 

Gummatous  Ulcer. — Gummatous  ulcer  begins  as  an  infiltration,  which 
shortly  (weeks)  softens  and  discharges  characteristic  pus  through  a 
central  round,  punched-out  opening.  A  suggestive  history  and  evidences 
of  other  lesions  are  usually  to  be  found. 

Lupus  in  either  its  superficial  or  deep  form  presents  characteristic 
symptoms. 

Perforating  ulcer  of  the  foot,  commonly  observed  in  middle-aged  or 
elderly  men  who  are  suffering  from  arteriosclerosis,  lesion  of  the  spinal 
cord  or  peripheral  nerves,  chronic  nephritis,  or  diabetes  mellitus,  is 
characterized  in  its  beginning  by  a  callosity  at  a  point  of  pressure,  usually 
to  the  inner  or  outer  side  of  the  sole  beneath  the  heads  of  the  metatarsals, 
followed  by  ulceration  beneath  this  cornified  layer  with  slowly  progressive 
destruction  of  the  deeper  tissues.  The  diagnosis  is  based  upon  the  pain- 
less persistence  of  the  lesion  and  its  tendency  toward  deep  rather  than 
peripheral  extension. 

Mycetoma,  or  Madura  Foot. — Mycetoma,  or  Madura  foot,  usually  an 
infection  of  the  tropics,  exceptionally  observed  in  the  temperate  zone, 
and  affecting  adults  who  walk  barefooted,  is  characterized  in  its  beginning 
by  nodulation  of  the  skin  of  the  sole  following  traumatism  or  abscess. 
The  nodule  slowly  extends  both  peripherally  and  in  depth  and  becomes 
riddled  with  sinuses.  Diagnosis  is  based  upon  the  multiple  sinuses,  the 
enormous  chronic  thickening,  particularly  marked  about  the  sole,  and 
essentially  by  the  finding  in  the  pus  of  the  yellowish  or  blackish  granules 
which  contain  the  Streptothrix  madurse. 

Gangrene  of  the  Foot. — Gangrene  of  the  foot,  when  due  to  arterio- 
sclerosis, is  often  preceded  by  harassing  pain.  The  starting  point  is 
usually  a  dermal  trauma  or  ulceration.  It  is  characterized  by  a 
mummification  incident  to  the  gradual  obliteration  of  blood  supply. 


564  THE  LOWER  EXTREMITY 

The  moist  gangrene  due  to  the  sudden  circulatory  obstruction,  which 
may  be  local,  incident  to  destruction  or  overwhelming  infection,  or  may 
involve  the  main  vessels  of  supply  (trauma,  thrombus,  embolus),  is  char- 
acterized by  putrid  sloughing  and  profound  toxemia.  When  it  occurs 
as  a  complication  of  lesions  in  themselves  trifling,  angiosclerosis  with  a 
complicating  diabetes  or  nephritis  is  usually  present.  The  diagnosis  of 
gangrene  is  obvious. 

Traumatic  Affections  of  the  Foot  and  Ankle. — ^Aside  from  wounds, 
the  usual  injuries  of  the  foot  and  ankle  are  contusions  or  sprains.  Un- 
usual swelling,  unduly  prolonged  pain,  disability,  and  localized  tenderness 
to  deep  pressure  should  suggest  fracture. 

Dislocations  in  the  absence  of  complicating  lesions  are  comparatively 
rare. 

Contusion. — Contusions  of  the  sole  of  the  foot  are  often  attended  with 
severe  pain  and  marked  tenderness.  Marked  aggravation  of  these 
symptoms,  after  three  days  of  rest,  is  usually  indicative  of  suppuration. 
Local  heat,  leukocytosis,  and  fever  are  corroborative  signs. 

Persistent  deep  tenderness  and  disability  after  contusion  are  suggestive 
of  fracture  and  call  for  the  use  of  the  x-rays. 

Sprain. — Sprain  of  any  joint  of  the  foot  is  possible  and  is  characterized 
by  local  swelling  and  pain,  aggravated  by  motion.  If  these  symptoms 
are  unduly  severe  and  persistent,  bone  injury  should  be  excluded  by  the 
x-rays. 

Strain  of  the  Ankle-joint. — This  is  usually  due  to  forced  inversion  and 
inward  rotation,  exceptionally  to  eversion  and  outward  rotaton.  In  the 
latter  case  it  is  often  complicated  by  fracture  of  the  inner  malleolus, 
the  bone  yielding  rather  than  the  exceptionally  strong  inner  ligaments. 
Sprain  is  manifested  by  pain,  tenderness,  usually  located  below  and  in 
front  of  the  malleolus,  and  swelling  due  first  to  blood  effusion,  later  to 
inflammatory  reaction. 

Convalescence  from  simple  sprain  should  be  early  and  complete. 
When  there  remain  persistent  pain,  disability,  and  tenderness  in  spite 
of  treatment  appropriate  to  sprain,  this  in  itself  is  suggestive  of  compli- 
cating fracture  or  intra-articular  traumatism. 

Fractures  of  the  Bones  of  the  Foot  and  Ankle. — Fracture  of  the  meta- 
tarsals and  phalanges  exhibits,  in  addition  to  the  symptoms  of  sprain, 
crepitus  and  unnatural  mobility.  Eliciting  these  last  two  symptoms 
in  the  case  of  the  metatarsals  may  be  difficult  or  impossible,  the  diag- 
nosis being  then  suggested  by  the  persistent  sharply  localized  tenderness 
to  deep  pressure  or  to  sudden  thrusting  of  the  corresponding  toe  backward 
and  demonstration  by  the  x-rays. 

The  proximal  end  of  the  fifth  metatarsal  may  be  fractured  in  running 
or  jumping.  Usually  neither  crepitus  nor  preternatural  mobility  can 
be  elicited.  Pain  not  disabling  at  first  but  increasing  daily  in  severity 
and  sharply  localized  tenderness  being  the  only  symptoms. 

The  midmetatarsals  of  heavy  persons  or  those  carrying  weighty 
burdens  are  at  times  broken  by  a  slip  or  twist  occurring  at  that  period 
of  the  step  when   the  weight  is  thrown   on  the  forepart  of   the  foot. 


THE  FOOT   AND  ANKLE  565 

Moderate  pain  which  persists  and  grows  worse,  dorsal  swelling,  with 
late  ecchymosis  (hours,  days),  and  persistent  localized  tenderness  are 
the  usual  symptoms.  This  is,  at  times,  the  mechanism  of  the  painful 
and  disabled  foot  observed  in  soldiers  after  long  marches. 

Luxation  of  the  metatarsals  and  phalanges  is  usually  obvious  to 
inspection  and  palpation. 

Fracture  of  the  tarsal  scaphoid,  usually  the  result  of  a  fall  from  a 
height  on  the  toes,  is  characterized  by  pain,  localized  tenderness,  often 
crepitus.  Deformity  is  masked  by  swelling.  If  the  scaphoid  be  dis- 
placed, it  can  be  readily  felt. 

Diagnosis  is  made  by  the  x-rays. 

Fracture  of  the  Astragalus. — This  is  usually  due  to  falling  from  a 
height  and  alighting  on  the  feet.  The  fracture  may  be  simple,  running 
through  the  neck  and  breaking  the  bone  into  two  parts,  with  or  without 
forward  displacement  of  the  anterior  fragment.  It  is  usually  commin- 
uted, representing  a  crush,  and  is  further  complicated  by  a  break  of  the 
OS  calcis. 

Severe  pain,  absolute  crippling,  possibly  crepitus,  and  flattening  of  the 
foot  may  suggest  a  diagnosis.  Swelling  is  so  great,  however,  that  the 
a;-rays  are  usually  needful.  Pain  and  disability  are  out  of  proportion  to 
that  customarily  observed  in  sprain,  nor  is  the  tenderness  so  definitely 
and  superficially  placed. 

Fracture  of  the  Calcaneum. — The  os  calcis  may  be  broken  in  its 
sustentacular  portion  or  through  any  part  of  the  body  or  tuberosity. 

Fig.  3471 


Instance  of  the  "os  trigonnm"  of  the  astragalus  existing  as  a  separate  ossicle,  in  a  male, 
aged  twenty-three  years.  Its  appearance  has  been  mistaken  for  fracture,  which  was  sug- 
gested at  first  in  this  case,  as  an  injury  was  followed  by  pain  and  local  tenderness  at  this  point, 
but  a  radiograph  of  the  opposite  ankle  showed  same  appearance  and  excluded  fracture. 

1  Figs.  347  to  353.  Fractures  involving  the  bones  of  the  tarsus.  Outline  drawings  from  radio- 
graphs by  Dr.  H.  K.  Pancoast  in  collection  ot  University  Hospital  a-ray  Laboratory;  patients 
referred  by  or  from  services  of  Drs.  White  and  Carnett,  and  from  dispensaries. 


566 


Fig.  348 


THE  LOWER  EXTREMITY 
Fig.  349 


Fig.  350 


I'll!.  3,51 


Figs.  348,  349,  and  350. — Unusual  injuries  in  regions  of  both  ankles  of  an  adult  male,  resulting 
from  fall  from  telegraph  pole,  landing  on  both  feet.  Fracture  of  posterior  and  outer  part  of  articular 
surface  of  tibia  in  each  ankle.  In  addition,  scaphoid  broken  in  left  tarsus;  fracture  astragalus  and 
compound  dislocation  ankle  right  side.  Latter  was  reduced  at  time,  and  radiographs  made  several 
weeks  later,  and  after  union  in  fractures.  Fig.  348,  anteroposterior  view  of  left  ankle,  shows  forward 
end  of  tibial  fragment  only.  Fig.  349,  lateral  view  of  same,  indicates  seat  of  latter  fracture  and  shows 
crush  of  scaphoid.  Fig.  350,  anteroposterior  view  right  ankle,  shows  fracture  of  entire  outer  margin 
of  articular  surface  of  tibia  and  slight  crushing  of  astragalus.  (Neither  shown  in  lateral  view,  which 
is  omitted.) 

Fig.  351, — Oblique  fracture  of  external  malleolus  of  fibula  and  crush  of  scaphoid,  in  an  adult 
male.  Former  easily  diagnosticated  clinically,  but  tarsal  injury  not  identified,  althougli  a  fracture 
somewhere  in  the  tarsus  was  suspected. 


Fissured  fracture  of  os  calcis,  without  displacement,  in  a  male,  aged  thirty-eight  years.  Line 
is  in  front  of  sustentaculum  and  attachments  of  calcaneoscaphoid  ligament,  and  more  anterior 
than  usual.  Clinical  diagnosis  of  fracture  difficult  in  such  a  case,  and  not  made  in  this  instance, 
injury  having  been  regarded  as  a  sprain  of  ankle,  but  patient  was  referred  for  usual  routine  i-ray 
examination. 

Fig.  353 


Comminuted  fracture  of  os  calcis  in  adult  male.  Arches  of  both  bone  and  foot  broken 
down,  implying  considerable  laceration  of  ligaments.  Injury  represents  unusual  amount  of 
violence.  Fracture  is  accompanied  by  a  disturbance  in  relations  of  tarsal  bones  suggestive 
of  a  subastragaloid  dislocation.  Clinical  diagnosis  not  exceptionally  difficult,  but  a;-ray  diagnosis 
easier,  more  certain,  and  more  hiunane.  Oval  body  under  calcaneocuboid  joint  probably  not  a 
fragment  of  bone,  but  an  ossified  sesamoid  often  found  here  (in  tendon  of  peroneus  longus)  and 
appearance  in  radiograph  sometimes  mistaken  for  fracture. 


568 


THE  LOWER  EXTREMITY 


Fracture  of  the  sustentaculum  has  been  characterized  by  sinking  of  the 
arch  and  simulation  of  the  valgus  deformity  of  Pott's  fracture.  Often 
the  injury  is  expressed  in  the  form  of  an  extensive  comminution. 

When  the  tuberosity  is  broken  there  may  be  marked  separation, 
owing  to  the  pull  of  the  tendo  Achillis,  making  the  diagnosis  easy.  In 
the  absence  of  such  separation,  flattening  of  the  longitudinal  arch, 
swelling  about  the  heel,  deep  tenderness,  and  pronounced  disability 
suggest  a  diagnosis  which  should  be  corroborated  by  the  ai-rays. 


Fig.  354 


Fig.  355 


Fig.  356 


Pott's  fracture.     (Hoffa.) 


Exaggerated  deformity  in  Pott's 
fracture.     (Park.) 


Deformity  following  Pott's  fractu 
Eversion  of  foot.  A  not  uncommon  seqi 
to  imperfect  reduction.  Serous  effusi 
in  ankle-joint. 


Potfs  fracture,  due  to  forcible  eversion  and  abduction,  is  character- 
ized by  a  tear  of  the  internal  lateral  ligament,  or,  if  this  be  sufficiently 
strong,  avulsion  of  the  tip  of  the  internal  malleolus,  and  a  fracture  either 
at  the  base  of  the  external  malleolus,  a  short  distance  above  this  point, 
or,  if  the  fall  be  such  as  to  forcibly  abduct  the  front  of  the  foot,  the  break 
may  be  oblique  and  at  a  much  higher  level.  The  tibiofibular  ligament 
is  ruptured  or  avulses  a  fragment  of  the  tibia,  and  the  astragalus  is  dis- 
placed outward,  or  it  may  be  jammed  upward  between  the  two  leg  bones 
if  they  are  widely  separated  or  the  outer  articular  surface  of  the  tibia 
is  split  off. 


THE  FOOT    AND  ANKLE 


569 


Fracture  of  a  single  malleolus  may  be  attended  by  but  moderate  im- 
mediate disability  and  no  deformity.  The  only  sign  of  fracture  may  be 
persistent,  deep  tenderness  at  the  seat  of  break,  associated  with  some 
joint  effusion. 

Supramalleolar  fractures,  commonly  due  to  jarring  weight  of  the  body, 
as  from  a  false  step,  associated  with  a  twist  of  the  foot,  usually  abduction, 
is  likely  to  be  comminuted  and  extremely  irregular.  Aside  from  crepitus, 
preternatural  mobility,  great  pain,  and  rapid  joint  swelling,  there  is  no 
means  of  accurately  determining  the  amount  of  injury  and  joint  displace- 
ment aside  from  the  a'-rays.     The  foot  may  be  displaced  in  any  direction. 

Separation  of  the  lower  epiphysis  of  the  tibia,  more  frequent  than  that 
of  its  upper  epiphysis,  usually  combined  with  fracture  of  the  fibula  and 
often  with  a  chipping  off  of  the  outer  tibial  articular  margin,  is  caused 
by  an  ankle  twist  (e version),  and  exhibits  the  characteristics  of  fracture. 
It  is  suggested  by  the  seat  of  the  transverse  break,  by  its  age  incidence 
(before  eighteen),  the  absence  of  intra-articular  blood  effusion,  and  par- 
ticularly by  the  x-rays.     The  foot  and  the  malleoli  are  usually  displaced 


Fig.  3571 


Fig.  358 


Figs.  357  and  358. — Fractiire  of  malleolus  of  fibula.  A  frequent  type  in  which  the  line  of  fracture 
extends  longitudinally  from  above  downward  and  behind  forward,  and  down  to  end  of  bone.  As 
a  rule,  it  shows  in  the  lateral  \'iew  only  (Fig.  358),  as  there  is  seldom  lateral  displacement.  Clinical 
diagnosis  often  difficult,  no  deformity,  and  preternatural  mobility  and  crepitus  not  obtainable  in 
many  instances.  Fracture  frequently  overlooked,  or  diagnosis  made  only  by  j-rays.  (Adult 
male,  aged  thirty-six  years.) 


1  Figs.  357  to  370.  Fractures  of  the  bones  of  the  leg  at  or  near  the  ankle.  Outline  drawings 
from  radiographs  by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray  Laboratory; 
patients  referred  by  or  from  services  of  Drs.  White,  Martin,  Frazier,  and  Carnett,  and  private  cases 
of  Dr.  Pancoast. 


570 


THE  LOWER  EXTREMITY 


Fig.  359 


Fig.  360 


Fig.  359. — Another  very  common  type  of  fracture  of  lower  end  of  fibula,  due  to  inversion.  In 
this  instance  the  break  shows  in  the  anteroposterior  view  only.  Patient,  an  adult  male,  could 
walk,  and  a  definite  clinical  diagnosis  of  fracture  could  not  be  made,  although  suspected  from  pain 
on  manipulation  and  local  tenderness. 

Fig.  360. — Fracture  both  malleoli,  in  adult  male,  resulting  from  a  jump  from  the  top  of  a  freight 
car.  Fibular  fracture  at  extreme  tip.  Both  show  in  anteroposterior  view  only.  Clinical  diag- 
nosis not  difficult. 

Fig.  361 


Fracture  of  lower  edge  of  inner  malleolus  of  tibia,  in  male,  aged  thirty-three  years.  Important 
because  of  possibility  of  rupture  of  external  lateral  ligament  instead  of  fracture  of  fibula.  Shows 
in  anteroposterior  view  only. 


Fig.  302 


THE  FOOT   AND  ANKLE 

Fig.  303 


571 


Figs.  362  and  363. — Fracture  both  bones;  tibia,  inner  malleolus,  and  posterior  portion  of  articular 
margin;  fibula,  shaft  at  lower  and  middle  fourths.  Adult  male.  Anteroposterior  view,  Fig.  362, 
shows  slight  outward  displacement  of  foot  and  fibular  fragments  not  in  apposition,  but  does  not 
show  posterior  tibial  fracture.  Lateral  view,  Fig.  363,  shows  almost  complete  posterior  disloca- 
tion at  ankle. 


backward  and  outward  with  an  obvious  change  in  the  relation  of  the 
malleoli  to  the  long  axis  of  the  bones. 

Luxation  of  the  Foot  and  Ankle.— Luxation  of  the  digits  and  the  meta- 
tarsal bones  exhibits  characteristic  deformity  and  disability.  It  is 
usually  due  to  direct  trauma,  and  is  often  complicated  by  destructive 
lesions  of  the  bones  and  soft  parts. 

The  displaced  scaphoid  in  the  absence  of  great  swelling  is  easily 
recognized  as  such. 

Subastragaloid  dislocations  may  be  in  any  direction.  The  relation 
of  the  malleoli  to  the  astragalus  is  not  disturbed,  but  the  foot  is  thrust 
forward,  backward,  inward,  or  outward,  and  is  fixed  in  its  position; 
characteristic  deformity  in  the  absence  of  great  swelling  can  be  detected. 
This  injury  is  often  complicated  by  fracture,  and  a  complete  diagnosis 
cannot  be  made  without  the  a;-rays.  • 

The  astragalus  may  be  driven  from  its  bed  between  the  os  calcis,  sca- 
phoid, tibia,  and  fibula,  forward  or  backward,  or  may  be  rotated.  The 
outward  and  forward  displacement  is  the  usual  one,  resulting  in  inward 
rotation  of  the  foot  with  the  displaced  bone  readily  palpable. 


572 


THE  LOWER  EXTREMITY 

Fig.  364 


Fracture  of  both  bones;  fibula  longitudinal  through  lower  fifth;  tibia,  posterior  margin  of  articular 
portion.  Male,  aged  twenty-three  years.  Lateral  view.  Neither  fracture  is  shown  in  the  antero- 
posterior view.     Diagnosis  of  tibial  fracture  difi&cult  clinically. 


Tihiotarsal  Dislocation. — ^The  foot  may  be  displaced  in  any  direction, 
usually  outward  and  forward,  with  a  complicating  fracture. 

Backward  dislocation  is  characterized  by  shortening  of  the  anterior 
part  of  the  foot,  lengthening  of  the  heel,  prominence  of  the  lower  articular 
surface  of  the  tibia  over  the  instep  where  its  sharp  anterior  rim  may  be 
felt,  unless  the  swelling  be  excessive,  and  tense  prominence  of  the  tendons 
of  the  back  of  the  ankle,  unless  the  leg  is  shortened  by  a  complicating 
fracture  of  the  tibia. 

Associated  malleolar  fracture  with  great  swelling  and  tenderness, 
may  so  obscure  diagnosis  as  to  make  the  x-rays  or  examination  under 
ether  needful. 

Outward  and  inward  luxations,  characterized  by  obvious  deformity, 
are  necessarily  complicated  by  malleolar  fracture. 

Upward  luxation,  in  which  the  astragalus  is  driven  between  the  tibia 
and  fibula  results  in  fixed  foot  with  an  apparent  depression  of  the  malleoli, 
almost  to  the  level  of  the  sole,  and  a  lateral  separation  so  pronounced  as 
to  be  obvious  to  inspection  and  mensuration. 

Luxation  of  the  Tendons. — Luxation  of  the  tendons,  usually  of  the 
peronei  (rare)  incident  to  violent  muscular  action,  is  characterized  by 
severe  pain,  pronounced  disability,  local  tenderness,  and  palpation  of 
the  displaced  tendons,  which  usually  can  be  snapped  back  into  place. 


Fig.  365 


THE  FOOT  AND  ANKLE 

Fig.  366 


573 


Figs.  365  and  366. — Epiphyseal  separation  of  lower  end  of  tibia  with  posterior  displacement  of 
epiphysis,  carrying  with  it  a  fragment  of  posterior  portion  of  diaphysis.  Patient,  a  boy  about 
sixteen  years  of  age,  caught  his  foot  on  the  top  bar  when  jumping  a  hurdle.  Clinical  diagnosis  of 
exact  nature  of  injury  difficult,  but  a  correct  diagnosis  and  accurate  reduction  were  essential. 
Anteroposterior  view,  Fig.  365,  gives  practically  no  information  in  this  instance.  Fig.  366,  lateral 
view. 

Fig.  367 


Longitudinal  fracture  of  lower  end  of  tibia,  with  separation  of  anterior  portion  of  bone  which 
is  displaced  relatively  forward  with  foot.  Injury  resulted  from  patient,  a  physician,  being  thrown 
from  his  carriage.  Exact  mechanism  not  known,  as  there  were  numerous  other  injuries.  Clinical 
diagnosis  of  exact  nature  of  injury  difficult.     Lateral  view. 


574 


THE  LOWER  EXTREMITY 
Fig.  368 


Longitudinal  fracture  of  the  posterior  aspect  of  the  tibia  extending  downward  to  about  middle  of 
lower  articular  surface.  Patient  an  adult  male.  Injury  caused  by  wheel  of  an  automobile  passing 
over  the  part.  No  displacement.  This  fracture  could  not  be  diagnosticated  clinically,  although 
one  was  suspected,  mainly  because  of  inability  of  patient  to  walk  on  foot.  Anteroposterior  view 
shows  no  indication  of  a  fracture.     (Lateral  view.) 


Rupture  of  the  Tendons. — Rupture  of  the  tendons,  usually  the  tendo 
Achillis,  frequently  incomplete,  is  characterized  by  pain,  partial  or 
complete  disability,  local  tenderness,  and  the  detection  of  a  break  in 
continuity  on  palpation.  This  gap  becomes  promptly  filled  with  blood, 
hence  firm  pressure  may  be  needed  to  detect  its  presence. 

Tenosynovitis. — ^Tenosynovitis,  or  peritendinitis,  in  the  region  of  the 
ankle-joint,  commonest  about  the  tendo  Achillis,  often  affecting  the 
sheaths  of  the  peronei  and  the  tibialis  anticus  and  digital  tendons,  usually 
due  to  prolonged  and  unwonted  use,  at  times  a  local  expression  of  infec- 
tion, particularly  that  incident  to  gonorrhea  or  rheumatism,  is  character- 
ized by  pain  on  movement,  tenderness  and  swelling  along  the  course  of 
the  tendon,  and  often  fine  crepitation. 

The  tuberculous  form,  commonly  secondary  to  bone  or  joint  involve- 
ment, is  characterized  by  insidious  onset,  slow  progression,  and  a 
fluctuating,  often  loculated  and  crepitating  swelling  along  the  course 
of  the  tendon  sheaths.  In  the  tuberculous  ulcerative  form  there  is 
soft  infiltration  and  abscess  formation. 

Retrocalcaneal  Bursitis. — Retrocalcaneal  bursitis,  or  inflammation  of 
the  bursa  between  the  os  calcis  itself  and  the  tendo  Achillis,  commonly 
due  to  excessive  use  or  a  local  expression  of  general  infection,  particularly 
gonorrheal  rheumatism,  is  expressed  by  pain  increased  on  motion,  and 
tenderness  and  swelling,  best  elicited  by  pressure  to  either  side  of  the 
tendo  Achillis  just  above  its  insertion  into  the  os  calcis.     The  swelling 


THE  FOOT  AND  ANKLE 

Fig.  369  Fig.  370 


575 


Figs.  369  and  370. — Compomid  comminuted  fractxire  of  both  bones  at  ankle,  in  a  male,  aged 
thirty-four  years,  resulting  from  direct  violence — crush  by  a  car  wheel.  (Other  leg  similarly  broken 
higher  up.)  Clinical  diagnosis  of  exact  nature  of  injury  difficult.  Lateral  view.  Fig.  370,  shows 
in  addition  a  posterior  luxation  of  ankle  and  foot  with  the  lower  fibular  and  lower  and  posterior 
tibial  fragments,  complete  reduction  of  which  could  not  be  accomplished. 


is  usually  hard,  nor  is  fluctuation  readily  demonstrable.  The  acute 
affection  may  become  chronic. 

Inflammation  affecting  the  bursa  on  the  lower  surface  of  the  os  calcis 
may  be  secondary  to  trauma,  an  evidence  of  fissured  fracture  or  a  local 
manifestation  of  constitutional  infection.  It  is  not  infrequently  accom- 
panied by  periosteal  outgrowth  in  the  form  of  a  spur.  The  diagnosis 
is  suggested  by  the  a--rays,  but  must  often  be  tentatively  made  by 
exclusion. 

Inflammation  of  the  Joints  and  Bones  of  the  Foot  and  Ankle. — 
Acute  Arthritis. — Acute  arthritis,  commonest  in  the  ankle-joint,  if  trauma 
and  direct  infection  be  excluded  as  causes,  is  usually  incident  to  systemic 
infection,  particularly  that  due  to  rheumatism  and  the  gonococcus. 
Any  of  the  infections  may,  however,  be  expressed  in  the  joints  of  the  foot. 
The  symptoms  are  those  of  arthritis,  namely,  pain  aggravated  by  motion 


576  THE  LOWER  EXTREMITY 

involving  the  joint,  tenderness  and  swelling  about  the  joint,  limitation 
of  motion,  and,  in  the  case  of  pyogenic  infection,  constitutional  symp- 
toms. 

Acute  Arthritis  of  the  Metatarsophalangeal  Joint. — Suppurative  arthri- 
tis of  this  joint  is  usually  secondary  to  an  infected  bunion.  It  is 
characterized  by  pain,  swelling,  and  disability  out  of  proportion  to  the 
original  lesion  and  wide  of  it,  by  the  rapid  (days)  formation  of  fistulse 
leading  into  the  interior  of  the  joint  and  by  extension  of  pus  beneath  the 
deep  fascia  of  the  sole.  There  is  local  tenderness,  edema  of  the  dorsum 
of  the  foot,  and  a  tendency  to  point  between  the  great  toe  and  the  one 
lying  next  to  it. 

Gout  particularly  manifests  itself  in  the  metatarsophalangeal  joint 
of  the  great  toe.  It  is  marked  by  the  sudden  onset  of  the  local  symp- 
toms of  a  violent  inflammation  without  adequate  cause  or  correspond- 
ing constitutional  symptoms.  A  similar  inflammation  of  the  joint,  but 
one  less  violent  in  onset  and  slower  in  subsidence,  follows  tonsillitis 
and  other  forms  of  infection  localized  elsewhere.  As  in  other  parts 
of  the  body,  the  gouty  toe  has  a  tendency  to  exhibit  chalky  deposits 
with  final  degeneration  and  ulceration. 

The  red,  edematous,  painful,  and  exquisitely  tender  swelling  of 
acute  gout  closely  simulates  a  pyogenic  infection.  It  often  follows 
slight  trauma.  The  inadequacy  of  the  cause,  the  absence  of  marked 
constitutional  symptoms,  the  limitation  of  the  inflammation  to  the  peri- 
articular structures,  and  the  history  of  the  case  are  usually  sufficiently 
characteristic. 

Acute  arthritis  of  the  tarsal  and  metatarsal  joints,  in  its  suppurative 
form  usually  secondary  to  infected  wounds  or  suppuration  of  the  soft 
parts,  is  characterized  by  the  seat  of  swelling  and  tenderness,  rapid  and 
multiple  fistulization,  and  the  tendency  to  spread  along  the  tendon 
sheaths  of  the  leg. 

The  tarsal  and  tarsometatarsal  joints  are  subject  to  both  gonococcal 
and  rheumatic  inflammation  of  crippling  severity. 

Acute  arthritis  of  the  ankle-joint,  characterized  by  pain,  fixation  in 
slight  plantar  flexion,  swelling,  and  tenderness  most  marked  to  either 
side  of  the  extensor  tendons  anteriorly  and  between  the  tendo  Achillis 
and  the  malleoli  posteriorly,  may  develop  in  the  serous,  fibrinous,  or 
suppurative  form.  The  diagnosis  of  the  causative  lesion  is  dependent 
upon  the  recognition  of  the  systemic  infection,  usually  gonorrhea  or 
rheumatism. 

The  gonococcal  arthritis,  except  in  its  ephemeral  serous  form,  is 
characterized  by  an  especial  intensity  and  persistence  of  pain,  an  early 
involvement  of  tendon  sheaths  and  a  tendency  toward  ankylosis. 
The  grippal,  exanthematous,  typhoidal,  and  pneumococcal  infections 
are  in  themselves  not  characteristic. 

The  suppurative  arthritis  incident  to  infected  wound,  osteomyelitis, 
suppurating  tenosynovitis  is  characterized  by  the  rapid  onset  and  pro- 
gression of  both  the  local  and  general  symptoms  of  sepsis. 

Suppuration  complicating  pyemia  does   not  materially   add  to  the 


THE  FOOT  AND  ANKLE  577 

severity  of  the  constitutional  symptoms,  nor  are  the  local  signs  as 
pronounced  as  they  would  be  from  a  traumatic  pyogenic  infection. 

Chronic  Arthritis. — Chronic  arthritis  of  the  joints  of  the  foot  and  ankle, 
when  beginning  insidiously  is  usually  tuberculous.  It  may  be  post- 
traumatic or  may  follow  any  of  the  acute  forms  of  infection,  ^^^len  no 
other  cause  can  be  assigned,  it  is  termed  rheumatic. 

When  accompanied  with  deformity  out  of  all  proportion  to  the  pain 
and  disability  it  is  usually  tabetic. 

Post-traumatic  arthritis  usually  incident  to  unrecognized  fracture,  or 
one  in  which  perfect  restoration  of  normal  mechanical  conditions  has 
not  been  accomplished,  is  characterized  by  pain,  tenderness,  limited 
function,  muscular  atrophy,  and  at  times  bone  thickening  and  deformity 
so  great  as  to  suggest  malignant  infiltration  or  tuberculosis. 

The  diagnosis  of  the  cause  of  the  condition  is  usually  dependent  upon 
rr-ray  examination,  but  must  often  be  made  by  exclusion,  by  careful 
consideration  of  the  history,  and  by  observation  of  the  clinical  com-se. 
The  tibiotarsal  and  midtarsal  joints  are  particularly  affected  by  this 
form  of  chronic  arthritis. 

Tuberculous  Arthritis. — ^Tuberculosis  of  the  tibiotarsal  joint,  commonly 
secondary  to  involvement  of  the  astragalus  or  the  tibial  epiphysis,  is 
manifested  at  first  by  a  serous  effusion,  the  fluctuating  swelling  incident 
to  which  is  detected  to  either  side  of  the  extensor  tendon,  later  by  a 
uniform,  elastic,  indolent  swelling  involving  the  entire  joint. 

Pain,  limp,  limitation  of  motion,  muscular  atrophy,  onset  and  pro- 
gression without  other  adequate  cause,  and  reaction  to  tuberculin  are 
characteristic  features. 

Tuberculosis  of  the  midtarsal  joint  is  characterized  by  the  seat  of 
swelling  which  is  placed  in  front  of  the  malleoli.  Flexion  and  ex- 
tension movements  are  those  least  limited  and  least  painful. 

The  serous  effusion  of  the  ankle-joint  incident  to  acute  inflammation 
of  the  lower  epiphysis  of  the  tibia  (rare)  can  be  distinguished  from 
a  true  arthritis  only  by  the  history  of  the  onset  of  inflammatory  symp- 
toms, the  seat  of  maximum  pain  and  tenderness,  and  possibly  the  a:-rays. 

The  calcaneum  is  more  frequently  tuberculous  than  any  of  the  other 
tarsal  bones.  Nor  is  the  extension  of  the  process  so  likely  to  invade  the 
joints.  The  affection  is  characterized  by  an  indolent,  slowly  progressive 
thickening  of  the  bone,  the  swelling  being  most  pronounced  below  the 
malleoli  and  its  bone  limitations  being  most  distinctly  marked  when  the 
infection  lies  farthest  back.  The  ankle  motions  are  not  painful  and  are 
but  little  restricted.  The  x-tsljs  supplemented  by  the  tuberculin  test 
are  diagnostic. 

If  the  calcaneo-astragaloid  joint  is  involved,  the  submalleolar  swelling 
is  less  distinctly  outlined,  and  inversion  and  eversion  are  painful  and 
are  markedly  limited. 

Tuberculosis  of  the  metatarsals  (rare)  affecting  by  preference  that  of 

the  great  toe  in  adults,  usually  involves  several  bones.     It  is  characterized 

by  an  indolent,  fusiform  swelling,  exhibiting  a  tendency  toward  softening 

and  fistulization.     The  distinction  from  syphilis  is  difficult,  and  depends 

37 


578 


THE  LOWER  EXTREMITY 

Fig.  371 


Tuberculous  arthritis  of  ankle-joint.  Patient  aged  twenty-two  years.  Joint  symptoms  for  six 
months.  Swelling  most  marked  on  outer  and  inner  aspects  of  ankle.  Motion  limited.  Position 
one  of  moderate  plantar  flexion.  Fluctuation  present.  No  heat  or  redness.  Crepitation  of  joint 
surfaces.     Atrophy  of  leg  muscles. 

Fig.  372 


Gumma  of  ankle. 


Superficial  sloughing  ulcer  of  roimded  outline  and  imdermined  edges, 
lesion    on    shoulder. 


Similar 


THE  LEG  579 

in  the  early  stages  upon  the  history,  results  of  the  tuberculin  test  and 
mercurial  treatment,  and  finally  upon  the  microscope. 

Tabetic  Arthropathy. — ^Tabetic  arthropathy,  usually  of  slow  develop- 
ment, often  preceding  other  symptoms  of  the  disease,  is  characterized 
by  swelling  and  deformity  which  may  ultimately  become  grotesque 
without  the  usual  amount  of  pain,  tenderness,  and  fixation.  The  mid- 
tarsal  or  the  tibiotarsal  joint,  commonly  both,  are  involved.  The 
appearance  may  be  suggestive  of  sarcoma.  The  want  of  correlation 
between  the  subjective  and  objective  symptoms  is  almost  diagnostic. 

Tumors  of  the  Foot. — Of  the  benign  neoplasms,  lipoma  is  perhaps 
the  commonest  and  may  be  congenital.  It  exhibits  the  softened  consist- 
ency and  the  slow  growth  of  this  neoplasm  as  observed  elsewhere. 

Exostoses  are  not  uncommon  in  the  heel,  where  they  may  give  rise  to 
pain  on  walking  before  they  form  a  sufficient  enlargement  to  be  detected 
by  palpation.     Diagnosis  may  be  made  by  the  x-rays. 

A  subungual  bony  outgrowth,  springing  from  beneath  the  nail  of 
the  great  toe,  occasions  in  its  early  stage  of  growth  pain  on  pressure. 
Later,  it  lifts  the  nail.  Thfe  slow  growth  (months,  years)  without  inflam- 
matory symptoms,  the  dense  consistency  when  palpation  is  possible,  and 
the  a;-rays  establish  the  diagnosis. 

Chondroma,  frequently  multiple,  having  for  its  seats  of  predilection 
the  metatarsals  and  phalanges,  is  characterized  by  dense  nodulation, 
slow  growth,  and  negative  x-ray.  findings. 

Epithelial  cysts  are  observed  on  the  sole  as  on  the  palm. 

Angioma  is  often  associated  with  a  fatty  growth;  it  is  usually  indicated 
by  involvement  of  the  skin  vessels.  The  changes  in  size  incident  to 
vascular  tension  are  characteristic. 

Sarcoma,  occasionally  congenital,  growing  from  either  the  skin,  sub- 
cutaneous tissues,  or  the  bones,  can  be  distinguished  from  benign 
lesions  only  by  its  rapid  course. 

Developing  as  a  subungual  growth,  if  of  slow  progression,  it  cannot  be 
distinguished  from  subungual  osteoma  except  by  excision  and  micro- 
scopic examination.  Osteosarcoma  simulates  in  its  early  stages  chronic 
inflammation  of  the  bone.  The  x-rays  give  a  fairly  characteristic  picture. 
In  its  further  development  the  bone  tumor  forms  a  more  distinctly  out- 
lined mass  than  do  the  inflammatory  lesions,  nor  does  it  show  an  early 
tendency  toward  softening  or  fistulization.  The  metatarsals,  the  pha- 
langes, and  the  calcaneum  are  the  bones  most  commonly  invaded. 

Sarcoma  should  be  diagnosticated  by  excision  and  microscopic  exami- 
nation, the  operation  being  performed  when  the  tumor  is  first  located 
by  the  x-rays,  provided  it  is  probably  not  specific. 


THE  LEG. 

The  crest  of  the  tibia  is  subcutaneous  and  readily  palpable  through 
its  whole  extent.  The  head  of  the  fibula  and  the  lower  third  of  its 
shaft  can  also  be  felt. 


580 


THE  LOWER  EXTREMITY 


The  abrasions  and  contused  wounds  to  which  the  skin  overlying 
the  tibial  crest  and  the  malleoli  is  subject,  because  of  a  dependent  posi- 
tion, constant  use  of  the  part,  and  often  an  associated  valvular  incompe- 
tence of  the  veins,  are  slow  to  heal.  These  lesions,  whether  they  become 
acutely  and  repeatedly  inflamed  or  develop  into  chronic  ulcers,  are 


Fig.  373 


Long  saphenous  vein, 


Vastus  externus  m. 

Rectus  femoris  m. 
Vastus  internus  m. 


Tendon  of  quadriceps  femoris;  sub- 
femoral  bursa  beneath  it. 

Patella  covered  by  prepatellar  bursa. 


Line  of  knee-joint. 

Tendo  patellae. 
Inner  tuberosity  of  tibia. 
Anterior  tibial  tubercle. 
Head  of  fibula. 


Gastrocnemius  and  soleus  muscles. 

Crest  of  tibia. 

Tibialis  anticus  muscle. 

Extensor  longus  digitorum  muscle. 

Peroneus  longus  and  brevis  muscles 
covering  the  fibula. 


Surface  markings  of  the  leg  and  knee.     Anterior  surface.     (G.  G.  Davis.) 


accompanied  by  an  obstructing  or  obliterating  lymphangitis  which 
renders  reparative  processes  slow  and  incomplete.  Hence  the  leg  is 
the  common  seat  of  chronic  ulcers. 

Varicose   veins   of  the   leg,   fundamentally  incident    to    incompetent 
valves,  are  usually  attributable  to  prolonged  standing,  or  interference 


THE  LEG 


581 


with  the  return  flow,  as  from  intra-abdominal  pressure,  thrombosis, 
tumor  formation,  or  mitral  regurgitation. 

Varicose  veins,  if  superficial,  are  obvious  to  inspection  and  palpation. 
If  deep,  they  are  characterized  by  pain  of  a  rheumatic  character  made 
worse  by  standing,  edema  about  the  ankle  not  otherwise  to  be  accounted 
for,  and  dilatation  of  the  small  veins  over  the  dorsum  of  the  foot. 

Superficial  varices  are  usually  dependent  for  their  progression  upon 
valvular  incompetence  in  the  long  saphenous  vein.  A  similar  condition 
in  the  short  saphenous  vein  is  less  common.  Valvular  incompetence 
is  determined  by  holding  the  leg  and  thigh  in  a  vertical  posture  for 
several  minutes  with  the  patient  supine.     The  lower  third  of  the  thigh 

Fig.  374 


Lymphedema  of  the  leg.  Extensive  inflammatory  exudate  in  left  pelvis.  Swelling  in  part 
disappeared  mider  prolonged  rest  in  bed,  but  recurred  on  getting  up.  Diffuse,  firm  swelling, 
yielding  slight  pitting  on  pressure,  extending  to  top  of  shoe  and  crippling  in  character. 


is  then  bandaged  with  sufficient  pressure  to  compress  the  superficial 
but  not  the  deep  veins,  and  the  patient  is  put  upon  his  feet.  If  the 
saphenous  vein  fills  abruptly  above  the  bandage,  the  valves  are  certainly 
incompetent. 

Varicose  veins  are  complicated  by  eczema,  leg  ulcer,  rupture  and 
hemorrhage,  thrombosis,  embolism,  and  the  formation  of  phleboliths. 

Thrombosis  is  characterized  by  the  appearance  of  a  tender  cord  in 
the  course  of  the  vein,  usually  accompanied  by  edema  and  skin  red- 
ness. If  septic,  the  thrombus  exhibits  the  features  and  constitutional 
symptoms  of  abscess.  The  nodular,  subcutaneous,  usually  multiple 
phleboliths  are  the  traces  of  former  thrombosis. 


582 


THE  LOWER  EXTREMITY 


Chronic  Ulcer  of  the  Leg. — Chronic  ulcer  of  the  leg  may  be  incident 
to  the  action  of  the  ordinary  pyogenic  organisms  upon  an  ill-drained, 
poorly  vascularized  skin  and  subcutaneous  area,  may  be  syphilitic, 
blastomycotic,  tuberculous,  or  malignant,  or  may  be  an  ultimate  skin 
expression  of  suppurating  bone  lesion. 

Simple  chronic  ulcer,  often  associated  with  obvious  varicosities,  is 
observed  at  times  in  overfat,  middle-aged  people;  usually  in  the  aged, 
ill-nourished,  and  uncleanly.  It  has  for  its  beginning  an  abrasion,  a 
wound,  an  inflamed  thrombus,  a  ruptured  varicose  vein,  or  a  patch  of 


Fig.  375. 


Giimina  of  subcutaneous  tissue.     Painless,  causeless,  indurated,  adherent  to  skin, 
over  the  underlying  bone.     Duration,  weeks. 


Freely  movable 


eczema.  The  affection,  usually  above  the  malleoli  and  on  the  lower 
third  of  the  leg,  is  characterized  by  indolence  and  slow  extension  (months, 
years)  which  is  mainly  superficial,  but  may  destroy  tissues  down  to 
the  bones. 

It  is  usually  painless  and  unattended  with  constitutional  symptoms; 
there  is  commonly  an  associated  pronounced  skin  pigmentation,  often 
obstinate  eczema,  occasionally  lymphedema,  producing  a  brawny  swell- 
ing of  the  foot  and  leg. 

Syphilitic  ulcer,  often  multiple,  begins  as  a  painless,  non-inflamma- 
tory infiltration  of  the  skin  or  underlying  soft  parts,  which  slowly. reddens 


THE  LEG 


583 


and  softens  (weeks),  leaving  a  deep,  punched-out,  rounded  ulcer  with 
bacon-like  walls.  It  is  common  in  the  upper  third  of  the  leg,  a  position 
so  unusual  for  simple  ulcer  that  this  in  itself  is  suggestive.  When  it 
occurs  over  the  regions  favored  by  simple  ulcer  and  is  not  seen  until  its 
characteristic  features  are  obscured  by  inflammation  incident  to  irrita- 
tion and  neglect  of  treatment,  the  diagnosis  must  depend  upon  the 
history,  the  presence  of  other  lesions  or  their  scars,  and  the  therapeutic 
test. 

Tuberculous  ulcer  is  usually  a  skin  manifestation  of  underlying  bone 
infection.  It  is  characterized  by  feeble  anemic  granulations,  under- 
mined skin,  and  a  tendency  to  fistulization. 

Fig.  376 


Gumma  of  leg.     Superficial  ulcerating  lesion,  circular  in  outline,  in  upper  half  of  leg.     Eight  weeks' 
duration.     Began  as  painless  swelling.     No  varicose  veins.     No  traiuna. 


Blastomycotic  ulcer  (rare)  appears  as  a  rounded,  spreading,  painless, 
indolent  area  made  up  of  exuberant  granulations  containing  multiple 
small  abscesses.     The  diagnosis  is  based  upon  microscopic  examination. 

Malignant  degeneration  of  a  chronic  ulcer  (Marjolin's  ulcer)  may  be 
suggested  by  its  nodular  surface  and  border.  The  diagnosis  must  be 
made  by  the  microscope. 

Erysipelas  and  cellulitis  of  the  leg  conform  to  type,  nor  is  the  diagnosis 
difiicult.  Direct  extension  of  infection  from  the  foot  through  the  synovial 
sheaths  of  the  tendons  is  less  common  than  is  the  case  with  the  hand. 

Extension  by  the  lymphatics  and  veins  may  involve  either  the  super- 
ficial or  the  subaponeurotic  tissues. 


584  THE  LOWER  EXTREMITY 

Following  slight  foot  infections,  contusion  or  strain  of  the  leg,  or  in 
the  absence  of  these  predisposing  factors,  there  may  be  extensive  collec- 
tions of  pus,  either  beneath  the  skin,  or  subfascial  between  the  muscles 
characterized  by  local  and  general  symptoms  of  such  moderate  severity 
that  diagnosis  is  not  formulated  until  fluctuation  is  developed. 

Such  purulent  collections  may  gravitate  from  the  popliteal  space, 
may  be  an  extension  of  chronic  osteomyelitis  of  the  bones  with  perfora- 
tion, or  may  be  secondary  to  deep  thrombosis. 

Contusion. — Contusion  of  the  leg  is  often  attended  by  extensive  blood 
extravasation,  producing  a  skin  discoloration  not  unlike  gangrene — the 
similarity  is  the  greater  if  the  skin  be  raised  in  the  post-traumatic  bullae 
which  often  complicate  fracture. 

Fig.  377 


Bleb  and  vesicles  following  (hours)  severe  contusion  of  the  leg.      (Frazier.) 

Fracture  of  the  Bones  of  the  Leg. — ^The  tibia  and  fibula  are  commonly 
both  broken;  if  from  direct  violence,  at  the  point  of  application  of  this; 
if  from  indirect  violence,  the  fibula  at  a  higher  level  than  the  tibia,  even 
close  to  its  upper  extremity. 

The  common  seat  of  the  tibial  fracture  is  in  the  lower  third.  It  is  in 
direction  usually  oblique  from  above  and  behind  downward  and  for- 
ward. 

Spiral  fractures  from  twisting  force  are  common  and  are  usually 
comminuted.  Fissures  frequently  pass  downward  to  the  ankle-joint. 
The  lower  fragment  is  commonly  displaced  upward  and  backward. 

Diagnosis  is  usually  obvious  because  of  the  gross  deformity,  or  is 
readily  elicited  because  of  subcutaneous  position  of  the  tibial  crest. 
Crepitus  may  be  wanting  because  of  soft  parts  interposed  between  the 
fragments. 

Measurements  for  shortening  when  these  seem  needful  should  be 
taken  between  the  adductor  tubercle  and  the  internal  malleolus. 

When  the  associated  fibular  fracture  is  placed  high,  its  seat  may  be 
determined  by  local  tenderness  to  deep  palpation,  often  crepitus  and 
lessened  resistance  to  pressure  or  by  preternatural  mobility. 

Fracture  of  the  tibia  alone  may  occur  without  displacement,  in  which 
case  the  diagnosis  will  be  suggested  by  persistent  local  tenderness  and 


THE  LEG 


585 


moderate  disability.  It  is  possible,  however,  for  a  person  with  such 
fracture  to  be  comparatively  able-bodied.  The  rr-rays  constitute  the 
final  means  of  determining  not  only  the  presence  of  fracture,  but  its 
exact  seat  and  its  nature. 

Fracture  of  the  fibula  alone,  usually  in  the  middle  third  and  from 
direct  violence,  is  characterized  in  the  absence  of  displacement,  by  local 
pain  and  tenderness  on  deep  pressure;  usually  by  crepitus  and  obscure 
preternatural  mobility.  The  power  of  locomotion  is  not  materially 
interfered  with. 


Fig.  3781 


Fig.  379 


V  X 


'  / ;  ;"""""« 


Fig.  378. — Uncomplicated  fracture  in  upper  portion  of  shaft,  in  a  male,  aged  forty-six  years. 
Clinical  diagnosis  somewhat  difficult  in  absence  of  crepitus  and  because  of  thick  covering  of  muscles. 
Pain  and  local  tenderness  most  suggestive  signs. 

Fig.  379. — Uncomplicated  fracture  about  middle  of  the  shaft  in  a  male,  aged  thirty-one  years. 
Cause,  direct  violence. 


1  Figs.  378  and  379.  Fractures  of  the  shaft  of  the  fibula  above  the  lower  fifth.  Outline  drawings 
from  radiographs  by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray  Laboratory; 
patients  referred  from  services  of  Drs.  White  and  Frazier. 


586 


THE  LOWER  EXTREMITY 


The  lower  third  of  the  fibula  is  very  commonly  broken  as  a  further 
manifestation  of  an  everting  force  which  ruptures  the  internal  lateral 
ligament  of  the  ankle-joint  or  tears  loose  the  bony  attachment.  The 
seat  of  fracture  is  usually  about  two  inches  above  the  malleolus  and  is 
characterized  by  eversion  of  the  foot,  loss  of  resistance  on  deep  pressure, 
marked  local  tenderness,  and  usually  crepitus. 

Fracture  of  the  upper  extremity  of  the  fibula  may  be  unattended  by 
the  ordinary  signs  of  the  lesion  aside  from  deep  and  persistent  tenderness. 
Because  of  the  close  relation  of  the  peroneal  nerve  and  the  neck  of  the 
fibula,  fracture  of  the  bone  in  this  position  is  sometimes  associated  with 


Fig.  3801 


Fig.  381 


Fig.  380. — Fracture  of  the  middle  and  upper  thirds  of  the  shaft  in  a  child,  aged  six  years. 
Cause,  direct  violence — struck  by  fender  of  trolley  car.  Typical  example  of  incomplete  fracture. 
Not  diagnosticated  clinically,  purely  an  a;-ray  diagnosis.     Anteroposterior  view. 

Fig.  381. — Old  and  partially  united  transverse  fracture  of  upper  and  middle  thirds  of  shaft  in  a 
male,  aged  fifty-three  years.  Was  never  diagnosticated  or  treated  for  a  fracture.  Radiograph 
made  because  of  a  second  recent  injury  (negative).  Note  excessive  callus  for  such  a  break.  Shows 
necessity  of  x-ray  examination  for  such  injuries,  even  in  absence  of  pathognomonic  signs  of  fracture. 
Anteroposterior  view. 


1  Figs.  380  to  386.  Fractures  of  the  shaft  of  the  tibia.  Outline  drawings  of  radiographs  by 
Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  x-ray  Laboratory;  patients  referred  from 
dispenisaries. 


Flq.  382 


THE  LEG 

Fig    ;-!83 


587 


Fig.  384 


c^ 


k^ 


Fig.  382. — Incomplete  fracture  middle  of  shaft  in  a  boy,  aged  five  years.  (Compound.)  Note 
bending  of  fibula  without  fracture.     Anteroposterior  view. 

Fig.  383. — Lateral  view  of  same  case,  shows  that  fracture  must  be  very  nearly  complete. 

Fig.  384. — Very  oblique  fracture  in  lower  third  of  shaft  in  a  boy,  aged  fifteen  years,  caused 
by  a  horse  falling  on  his  leg.     Clinical  diagnosis  not  difficult.     Lateral  view. 

either  rupture  or  contusion  of  this  nerve  trunk.  Such  injury  is  char- 
acterized by  pain  referred  to  its  course  of  distribution,  or  local  anesthesia 
and  extensor  palsy. 

Fractures  of  the  lower  third  of  the  leg  often  fail  to  unite.  This  con- 
dition is  characterized  by  prolonged  disability  and  recurring  pain  on 
use,  usually  there  is  an  enormous  growth  of  callus  and  preternatural 
mobility.  It  may  be  difficult  to  elicit  this  last  symptom.  The  findings 
of  the  x-rays  are  conclusive.  Fracture  from  trifling  cause  always  sug- 
gests an  underlying  bone  lesion.  In  the  case  of  the  tibia,  bone  cysts 
and  central  sarcomata  should  be  considered. 

Inflammation  of  the  Tibia  and  Fibula. — Osteoperiostitis  of  the 
tibia  in  its  acute  form  may  be  due  to  traumatism  or  may  appear  as  a 
local  expression  of  systemic  infection,  particularly  of  syphilis  or  tj^phoid. 

Acute  traumatic  osteoperiostitis,  incident  to  contusions,  is  characterized 
by  excessive  pain,  great  tenderness,  swelling  which  is  obviously  attached 


588 


THE  LOWER  EXTREMITY 


Fig.  385 


B'lQ.  38G 


Fig.  385. — Anteroposterior  view  of  same  case  as  Fig.  384.  Remarkable  in  showing  no  evidence 
whatever  of  the  fracture. 

Fig.  386. — Oblique  spiral  fracture  in  lower  fourth  of  shaft  in  a  man,  aged  seventy-eight  years. 
Clinical  diagnosis  not  difficult.  Reduction  (outward  displacement  and  shortening)  very  difficult. 
Anteroposterior  view  after  attempted  reduction.     (Lateral  shows  no  displacement.) 


to  the  bone,  and  often  a  permanent  thickening.  Diagnosis  from  fissured 
fracture  must  be  made  by  the  x-rays.  Secondary  suppuration  is  denoted 
by  aggravation  of  symptoms  with  increasing  edema. 

Syphilitic  osteoperiostitis,  which  exhibits  a  preference  for  the  tibia,  may 
occur  in  either  the  secondary  or  tertiary  stage  of  the  disease.  In  the 
form  of  painful,  extremely  tender,  rapidly  developed  nodules,  it  is  an 
early  secondary  symptom  which  yields  readily  and  completely  to  specific 
treatment. 

Gummatous  osteoperiostitis,  exhibiting  a  predilection  for  the  lower 
third  of  the  tibia,  develops  slowly  and  apparently  causelessly,  or  follow- 
ing inadequate  trauma.  It  is  at  times  painless,  or  may  be  extremely 
painful.  The  diagnosis  is  based  upon  associated  symptoms  of  syphilis 
and  the  prompt  yielding  to  mercurial  treatment. 

Typhoid  Osteoperiostitis. — Typhoid  osteoperiostitis  is  superficial,  sub- 
acute, usually  painless,  follows  the  type  as  seen  elsewhere.  Diagnosis  is 
based  upon  the  apparent  causelessness  of  a  superficial  subacute  osteitis 
other  than  a  preceding  attack  of  typhoid  fever. 

Acute  Osteomyelitis. — Acute  osteomyelitis  exhibits  a  special  predilec- 
tion for  the  tibia,  attacking  by  preference  the  ends  of  the  bone,  often 
involving  the  entire  shaft.  Epiphyseal  and  joint  involvements  are 
secondary  processes. 


THE  LEG 


589 


In  the  hyperacute  form  the  onset  is  characterized  by  the  constitu- 
tional symptoms  of  profound  sepsis,  while  locally  there  is  intense  pain 
which  may  be  referred  to  the  nearest  joint,  extreme  sensitiveness  to 
deep  pressure,  and  absolute  crippling.  Edematous  swelling  of  the  soft 
parts  rapidly  supervenes. 

The  effusions  in  the  knee  and  ankle-joints,  occurring  as  complications 
of  osteomyelitis  of  the  tibia,  is  in  the  early  stages  serous.  Later,  it  may 
become  seropurulent,  or  even  frankly  suppurative,  the  original  infection 
being  then  complicated  by  the  symptoms  of  a  purulent  arthritis. 

There  is  an  acute  non-suppurative  osteomyelitis  which  can  be  dis- 


FiG.  387^ 


Fig.  388 


Fig.  387. — Fracture  of  both  bones  at  about  junction  of  upper  and  middle  thirds  of  shafts,  and 
about  same  level,  tibia  being  comminuted.  Radiograph  made  several  weeks  after  injury,  and  indi- 
cates delayed  union  in  tibia  and  no  attempt  at  union  in  fibula.  Lateral  view.  (Male,  aged  thirty- 
five  years.) 

Fig.  388. — Fracture  of  both  bones  just  below  middle  of  shafts.  Both  oblique;  fibula  slightly 
comminuted  and  tibial  fracture  very  irregular.  This  fracture  somewhat  unusual  from  standpoint 
of  cause,  a  fall  from  a  roof,  patient,  a  boy,  aged  eleven  years,  landing  on  his  feet.  Note  fairly  good 
apposition  and  position  of  fragments  indicated  in  this  view  (fore-and-aft)  and  compare  with 
Fig.  389. 


1  Figs.  387  to  400.  Fractures  of  the  shafts  of  both  bones  of  the  leg.  Outline  drawings 
from  radiographs  by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  i-ray  Labora- 
tory; patients  referred  by  or  from  services  of  Drs.  Frazier,  White,  and  Martin,  and  private 
cases  of  Dr.  Pancoast. 


590  THE  LOWER  EXTREMITY 

Fig.  389  Fig.  390  Fig.  391 


Fig.  389. — Lateral  view  of  same  case  as  Fig.  388  Note  shortening  and  forward  displacement 
of  lower  fragments,  neither  of  which  is  indicated  in  anteroposterior  view. 

Fig.  390. — Fracture  of  both  bones  at  about  lower  and  middle  thirds  of  shafts,  transverse,  and  at 
same  level.  This  is  the  type  usually  resulting  from  direct  violence  at  seat  of  fracture.  Patient, 
male,  aged  twenty-four  years.  Anteroposterior  view  shown  here  indicates  only  an  angular  deform- 
ity.    (Compare  with  Fig.  391.) 

Fig.  391. — Lateral  view  of  same  case  as  Fig.  390.  Note  additional  deformity  shown  and 
raquiring  correction. 

tinguished  from  the  phlegmonous  form  only  by  its  slower  progress  and 
the  absence  of  pus  formation,  the  exudate  being  serous. 

The  subacute  form  of  osteomyelitis  may  develop  with  slight  constitu- 
tional symptoms,  moderate  pain,  tenderness  localized  in  the  bone,  and 
local  swelling.  The  exact  seat  of  inflammation  is  determined  by  the 
x-rays.  The  distinction  from  tuberculosis,  rare  as  a  primary  lesion  of 
the  shaft,  is  based  upon  the  seat  of  the  inflammation,  the  examination 
of  the  pus  discharge,  and  prompt  recovery  after  extrusion  or  removal 
of  the  sequestrum. 

The  diagnosis  of  the  chronic,  sclerosing,  non-suppurative  form  of  osteo- 
myelitis is  based  upon  the  persistence  of  pain,  tenderness,  and  disability, 
in  the  absence  of  pronounced  constitutional  symp'toms  and  the  findings 
of  the  x-rays.     The  onset  of  this  form  may  closely  simulate  that  of  acute 


THE  LEG 


591 


Fig.  392 


Fig    393 


Fig.  392  — Compound  comminuted  fracture  of  both  bones  at  about  lower  and  middle  thirds  of 
shafts,  with  fibular  break  at  a  slightly  higher  level.  Cause  was  a  fall  from  a  second-story  window,  the 
patient,  a  male,  aged  about  twenty-six  years,  landing  on  the  foot  of  this  side.  Compare  this 
fracture  with  the  one  represented  in  Figs.  388  and  389,  which  was  due  to  practically  the  same 
cause.     Fore-and-aft  view. 

Fig.  393. — Lateral  view  of  same  case  as  Fig.  392,  showing  excellent  apposition  of  fragments. 


osteomyelitis.  It  is  a  rare  affection,  complicated  at  times  by  acute 
suppurative  inflammation  in  other  bones,  or  sequent  to  a  previous 
osteomyelitis. 

Abscess  of  the  Tibia. — In  the  cancellous  structure  of  the  upper  part 
of  the  tibia  an  abscess  may  remain  partly  encapsulated  for  years,  giving 
no  symptoms,  save  tenderness  to  deep  percussion  and  pressure,  and 
thickening  of  the  bone,  either  palpable  or  demonstrable  by  the  x-rays. 

There  is  a  previous  history  of  acute  osteomyelitis,  non-progressive  in 
type,  subsiding  under  local  treatment  without  operation,  but  recurring, 


592 


THE  LOWER  EXTREMITY 

Fig.  394  Fig.  395 


Fig.  394. — Fracture  of  both  bones  at  about  junction  of  middle  and  lower  fourths  of  shafts. 
Both  oblique,  and  fracture  of  tibia  comminuted  and  tending  toward  the  so-called  "spiral", 
type.  Both  bones  broken  at  practically  the  same  level.  Anteroposterior  view  is  represented  and 
shows  complete  lateral  displacement  with  over-riding.     (Female,  aged  thirty-six  years.) 

Fig.  395. — Fracture  of  both  bones  at  different  and  unusual  levels — tibia  at  lower  and  middle 
thirds  of  shaft  and  fibula  just  above  its  malleolus.  Both  oblique  and  readily  permit  shortening. 
(Male,  aged  fifty-three  years.)     Anteroposterior  view. 


at  least  so  far  as  pain  and  tenderness  are  concerned,  at  irregular  intervals, 
and  usually  as  a  result  of  slight  trauma  or  overuse. 

Positive  diagnosis  is  suggested  by  the  x-rays,  and  is  made  by  trephin- 
ing the  bone.  Nor  can  timely  differentiation  from  central  sarcoma 
always  be  made  in  any  other  way. 

As  the  result  of  osteomyelitis  the  bone  may  be  extensively  destroyed 
or  its  growth  may  be  stimulated  or  inhibited,  with  the  local  resultant 
deformities. 

Tuberculosis. — Tuberculosis  of  the  bones  of  the  leg  is  usually  limited 
to    the   epiphysis,    manifesting   itself    mainly   in   the   form  of   chronic 


593 


Fig.  396 


Fig.  398 


Fig.  396. — Fracture  of  both  bones,  comminuted,  and  at  somewhat  different  levels,  tibia,  lower 
and  middle  fourths,  and  fibula  throughout  entire  lower  fifth.  (Adult  female.)  Anteroposterior 
view. 

Fig.  397. — Fracture  of  both  bones,  with  extreme  degree  of  difference  in  levels.  Both  broken 
obliquely,  tibia  in  lower  fourth  of  shaft  and  fibula  in  its  upper  fourth.  A  striking  example  of  the 
type  of  fracture  resulting  from  indirect  violence.  (Male,  aged  seventy  years.)  Anteroposterior 
^'iew. 

Fig.  398. — Fracture  of  both  bones  at  about  junction  of  middle  and  lower  thirds  of  shafts,  trans- 
verse, and  nearly  same  level.  Unusual  cause.  (Compare  with  Fig.  .390.)  Fracturing  force  must 
have  been  essentially  a  twisting  strain  resulting  from  an  attempt  to  board  a  rapidly  moving  car. 
Left  foot  was  fixed  on  step,  but  not  caught,  and  carried  forward,  while  the  body  and  extremity 
above  swimg  around  relatively.  (Male,  aged  twenty-three  years.) 
38 


594 


THE  LOWER  EXTREMITY 

Fig.  399  Fig.  400 


Fig.  399. — Compound  fracture  of  both  bones  at  same  level  and  just  above  ankle,  broken  tran=- 
versely,  and  in  addition  a  longitudinal  fissure  through  lower  tibial  fragment  extending  downward 
to  epiphyseal  line,  but  not  through  the  epiphysis.  Injury  resulted  from  direct  violence — crushed 
under  a  car  wheel.      (Male,  aged  eighteen  years.) 

Fig.  400. — Fracture  of  both  bones  at  different  levels,  tibia  at  junction  of  lower  and  middle 
thirds  of  shaft  obliquely,  and  fibula  comminuted  through  entire  malleolus.     (Adult  male.) 


arthritis.  Early  recognition  of  the  focus  of  infection  by  the  a;-rays  may 
be  the  means  of  saving  the  joint. 

Exceptionally  it  attacks  the  shaft  of  the  bone,  usually  as  an  extension 
from  the  epiphysis.  The  onset  is  insidious  and  slowly  progressive,  and 
there  is  a  tendency  tov^^ard  fistulization. 

When  the  tuberculous  process  invades  the  entire  shaft  of  the  bone 
(rare)  it  exhibits  a  more  acute  onset  than  is  usual  with  this  form  of 
infection,  but  is  thereafter  characterized  by  its  slow,  steady  progression 
and  the  ultimate  development  of  characteristic  fistulae  and  sequestra. 

Diagnosis  is  usually  based  upon  the  presence  of  tuberculous  lesions 
elsewhere,  the  result  of  the  tuberculin  test,  the  characteristic,  thin, 
cheesy,  purulent  discharge,  microscopic  examination,  and  particularly 
animal  inoculations. 


THE  KNEE 


595 


Fig.  401 


Tumors. — ^Malignant  tumors  originating  in  the  soft  parts  of  the 
leg  are  not  common.  A  cancerous  degeneration  of  a  chronic  ulcer  has 
been  mentioned.  Sarcoma  in  its  beginning  cannot  be  differentiated 
either  from  lipoma  or  fibroma,  excepting  by  excision.  This  should 
be  the  means  of  diagnosis. 

The  tibia  is  the  favorite  seat  of  bone  sarcoma,  both  in  its  periosteal 
and  central  form.  It  is  usually  placed  near  the  extremity  and  in  its 
early  stages  does  not  differ  in 
symptomatology  from  a  chronic 
or  subacute  osteomyelitis.  The 
periosteal  sarcoma  in  its  further 
development  forms  a  palpable 
tumor,  fusiform  and  not  exhib- 
iting either  the  nodulation  or  con- 
sistency of  exostoses  or  chondro- 
mata.  The  x-rays  are  strongly 
suggestive;  diagnosis  should  be 
made  by  operation. 

Persistent  deep-seated  pain  is 
the  usual  symptom  of  central 
sarcoma.  During  this  stage  a 
probable  diagnosis  can  be  made 
by  the  a;-rays.  It  should  be  cor- 
roborated if  gumma  can  be  ex- 
cluded by  immediate  operation. 
The  later  development  of  these 
tumors  is  usually  characterized  by 
rapid  growth  and  the  attainment 
of  large  dimensions  before  ulcer- 
ation or  fistulization  takes  place. 

Bone  cysts  usually  give  rise  to 
few  symptoms  other  than  a  slight 
enlargement  of  the  bone.  They 
are  slow  in  growth  and  their  pres- 
ence is  often  first  suggested  by 
spontaneous  fracture  on  slight 
traumatism.  The  a;-rays  are 
usually  diagnostic. 


Epithelioma.  Indolent  (years),  indurated, 
infiltrating,  fungating  lesion  growing  from  a 
chronic  ulcer. 


THE  KNEE. 

The  thick,  coarse  skin,  with  comparatively  little  subcutaneous 
fat,  covering  the  front  of  the  knee-joint,  is  more  redundant  and  freely 
movable  than  that  of  finer  structure,  and  provided  with  an  abundant 
panniculus  lying  at  the  sides  and  back  of  the  joint. 

The  patella,  with  the  leg  straight  and  the  quadriceps  relaxed,  is 
freely  movable  from  side  to  side,  and  readily  palpated  even  in  fat  sub- 
jects. 

The  condyles  of  the  femur,  of  which  the  internal  is  the  more  promi- 


596  THE  LOWER   EXTREMITY 

nent,  can  be  palpated,  the  adductor  tubercle  placed  at  the  upper  border 
of  the  inner  condyle  forming  its  most  prominent  bony  projection.  The 
inner  and  outer  tuberosity  of  the  tibia,  the  latter  being  more  prominent, 
the  end  of  the  fibula,  the  upper  extremity  of  which  is  about  a  finger^s 
width  below  the  line  of  the  joint,  the  tubercle  of  the  tibia  at  about  the 
same  level,  with  the  patellar  ligament  inserted  into  it,  are  all  easily 
identified. 

The  tendons  of  the  semitendinosus  and  semimembranosus  forming 
the  inner  upper  margins  of  the  popliteal  space,  and  of  the  biceps  forming 
its  outer  margin,  are  conspicuous  landmarks.  The  lymphatic  glands 
of  this  space  cannot  be  felt  in  normal  individuals.  They  occupy  a 
midline  position  and  drain  the  superficial  area  corresponding  with  the 
distribution  of  the  short  saphenous  vein,  including  a  part  of  the  sole 
and  the  knee-joint. 

To  either  side  of  the  patella  and  above  it,  excepting  in  fat  people, 
there  is  a  depression,  the  obliteration  of  which  is  characteristic  of  joint 
effusion.  The  depressions  at  the  sides  of  the  ligamentum  patellae,  best 
marked  in  moderate  flexion,  are  obliterated  in  fat  people  by  an  increase 
in  the  fat  pad,  which,  with  lateral  extensions,  normally  lies  between  the 
ligament  and  the  joint. 

The  line  of  the  joint  is  roughly  indicated  by  the  lower  border  of  the 
patella.  The  synovial  membrane  reaches  a  higher  point  over  the  front 
of  the  inner  condyle  than  it  does  over  the  outer.  It  usually  exhibits  an 
anterior  pouch  extending  for  a  distance  of  two  fingers'  breadth  above 
the  upper  border  of  the  patella.  This  prolongation  may  be  entirely 
separate  from  the  joint,  or  may  communicate  with  it  by  a  narrow 
opening. 

Of  the  many  bursse  placed  about  the  knee-joint,  those  most  frequently 
involved  in  surgical  affections  are :  the  prepatellar  bursse,  of  which  there 
may  be  three,  separate  or  intercommunicating,  lying  between  the  various 
layers  of  the  fibrous  investment  of  the  anterior  surface  of  the  patella; 
the  infrapatellar  bursa,  placed  between  the  ligamentum  patellse  and  the 
tubercle  of  the  tibia,  with  the  pad  of  fat  naturally  lying  in  this  position 
interposing  between  it  and  the  joint;  the  bursa  between  the  gastroc- 
nemius and  the  semimembranosus  tendon,  lying  to  the  inner  side  of  the 
popliteal  space  and  above  the  line  of  the  joint. 

The  tibia  normally  joins  the  femur  in  a  position  of  slight  varus. 

The  motions  of  the  knee-joint  are  flexion,  limited  by  contact  of  the  calf 
muscles  with  the  flexors  of  the  thigh,  extension  to  the  straight  position, 
and,  when  the  leg  is  moderately  flexed  on  the  thigh,  rotation;  this 
necessarily  implies  a  slight  degree  of  lateral  rocking. 

Surgical  affections  of  the  knee-joint  are  characterized  by  deformity, 
swelling,  pain,  tenderness,  muscular  contraction  and  atrophy,  and 
limitation  or  exaggeration  of  motion. 

Deformity,  usually  obvious  to  inspection  or  palpation,  may  require 
an  a;-ray  examination  for  its  detection.  The  swelling,  if  intra-articular, 
is  characterized  by  a  filling  out  of  the  normal  depressions  at  the  sides  of 
and  above  the  patella,  and,  if  it  be  due  to  effusion,  by  a  floating  up  of 


THE  KNEE 


597 


Fig.  402 


this  bone.     Extra-articular  swelling,  if  localized,  is  obvious  to  inspec- 
tion and  palpation. 

The  pain  of  knee-joint  affections,  unless  this  be  referred  (usually 
from  the  hip)  or  be  neuralgic  in  type,  is  aggravated  by  motion,  by  deep 
palpation  and  jarring,  and  is  subject  to  spasmodic  exacerbation  incident 
to  muscular  contraction. 

In  localized  lesions  the  seat  of  pain  and  tenderness  is  usually  indica- 
tive of  the  seat  of  lesion. 

Muscular  atrophy  develops  most  rapidly  and  is  most  pronounced  in 
the  quadriceps,  though  all  the  muscles  concerned  in  the  joint  move- 
ment become  involved. 

Limitation  of  motion,  if  incident  to 
an  inflammation,  is  due  in  the  early 
course  to  pain  and  muscular  spasm, 
later  to  fibroid  changes  or  bony  anky- 
losis. Exaggerated  lateral  or  antero- 
posterior movements  are  characteristic 
of  ligamentous  rupture  from  trauma  or 
of  overstretching  from  failure  of  muscle 
support  or  intra-articular  effusion. 

Deformities  of  the  Knee. — Gross 
congenital  deformities  such  as  absence 
of  the  patella  are  obvious  on  inspection. 

Genu  Recurvatum. — Genu  recurva- 
tum,  a  term  applied  to  over-exten- 
sion, may  be  congenital  or  acquired. 

The  congenital  form  is  often  accom- 
panied by  other  deformities,  particu- 
larly club  foot.  The  popliteal  space  is 
prominent,  and  there  may  be  inability 
to  flex. 

The  acquired  form  is  commonly  due 
to  club  foot  v^hich  places  an  undue 
strain  upon  the  knee.  Inherent  liga- 
mentous relaxation,  hip-joint  fixation, 
or  direct  injury  may  cause  this  de- 
formity. 

Pain,  discomfort,  and  hyperextension 
during  weight-bearing  are  the  charac- 
teristic features.  The  diagnosis  is  made 
by  inspection. 

Genu  Valgum. — Genu  valgum,  or  knock-knee,  which  usually  develops 
in  infancy  or  childhood,  exceptionally  about  the  period  of  puberty, 
incident  to  overuse,  is  commonly  attributed  to  rickets,  though  a  failure 
of  muscular  coordination  and  habitual  faulty  attitude  may  be  causative 
factors.  With  the  knees  pressed  together  and  the  patient  standing,  both 
tibiae  incline  downward  and  outward,  and  the  feet  are  more  or  less 
widely  separated.  The  condition  is  usually  bilateral  and  is  associated 
with  genu  recurvatum  and  flat  foot. 


Knock-knee  (genu  valgum).  Knees 
in  apposition.  Feet  widely  separated. 
Patient  in  habit  of  carrying  heavy  bas- 
kets, which  he  permitted  to  press 
against  outer  side  of  knees.     (Carnett.) 


598  THE  LOWER  EXTREMITY 

Genu  Varum. — Genu  varum,  or  bow  leg,  is  usually  dependent  upon  a 
deformity  not  of  the  knee-joint,  but  of  the  upper  portion  of  the  tibia. 
It  is  customarily  associated  with  inward  rotation  of  the  tibia  producing 
a  pigeon-toe  gait.     Diagnosis  is  obvious. 

Ankylosis. — ^Ankylosis  of  the  knee-joint,  either  bony  or  fibrous,  is  the 
after  result  of  previous  inflammation.  The  diagnosis  is  obvious  and  the 
amount  of  joint  destruction  can  best  be  determined  by  the  a;-rays. 

Contractures  of  the  knee-joint,  exceptionally  congenital,  frequently 
secondary  to  inflammation  in  or  about  the  joint,  or  sequent  to  infantile 
palsy,  are  characterized  by  partial  fixation  of  the  knee  in  a  faulty  posi- 
tion, usually  more  or  less  pronounced  flexion,  often  combined  with  out- 
ward rotation  and  subluxation  backward. 

Trauma  of  the  Knee. — The  immediate  effects  of  trauma  applied 
to  the  knee  are  wound,  contusion,  sprain,  fracture,  or  luxation.  The 
usual  injuries  are  contusion  and  sprain. 

Wound. — Wound  of  the  knee  is  obvious.  If  it  be  large  the  presence  or 
absence  of  joint  penetration  is  readily  determined.  Punctured  wound 
or  foreign  body  may  cause  a  synovial  effusion  even  though  the  joint  is 
not  involved.  In  case  of  doubt  as  to  the  nature  of  this  effusion,  aspira- 
tion and  examination  of  the  exudate  are  indicated. 

Contusion. — Contusion  of  the  knee,  if  it  involves  the  soft  parts  alone,  is 
characterized  by  moderate  and  ephemeral  pain,  rapid,  often  extensive 
skin  discoloration,  and,  if  the  prepatellar  bursa  be  involved,  a  blood 
effusion  into  the  sac  causing  a  distinctly  circumscribed  fluctuating  or 
semisolid  tumor. 

When  the  joint  is  contused,  usually  from  force  applied  to  the  inner  side 
of  the  patella  when  the  knee  is  flexed,  there  are  severe  persistent  pain, 
marked  disability  and  rapid  intra-articular  effusion  with  prompt  discolora- 
tion at  the  seat  of  impact. 

Because  of  the  immediate  swelling  and  the  extreme  tenderness,  asso- 
ciated cartilaginous  or  bone  lesions  usually  escape  detection  until  their 
presence  is  suggested  by  slow  and  unsatisfactory  convalescence.  The 
exclusion  of  bone  lesion  should  be  accomplished  by  the  ic-rays. 

Sprain. — Sprain  of  the  knee,  usually  involving  the  internal  lateral 
ligament,  and  incident  to  any  force  tending  to  exaggerate  the  natural 
slight  genu  valgum,  is  characterized  by  severe  pain,  local  tenderness, 
discoloration,  usually  effusion  into  the  joint,  and,  if  the  ligament  be  rup- 
tured, increased  lateral  mobility,  with  at  times  a  slight  displacement  of  the 
tibia  upon  the  femur,  the  former  bone  carrying  with  it  the  intact  semi- 
lunar cartilages.  This  condition,  really  a  recurring  subluxation  of  the 
tibia,  usually  due  to  considerable  violence,  constitutes  one  form  of  dis- 
location of  the  semilunar  cartilage,  and  is  characterized  by  a  weak  joint 
subject  to  sudden  painful  locking,  incident  to  slight  force  in  the  direction 
of  rotation  while  the  leg  is  semiflexed  and  the  muscles  are  relaxed. 
These  painful  lockings  are  followed  by  synovial  effusion. 

Subluxation  of  the  semilunar  cartilage,  usually  the  inner  and  in  a  for- 
ward direction,  is  due  to  forcible  inward  rotation  of  the  femur  upon  the 
flexed  tibia.     It  is  characterized  by  severe  pain,  usually  fixation  of  the 


THE  KNEE  599 

joint  in  flexion,  rapid  effusion,  tenderness  over  the  semilunar  cartilage, 
and  in  the  case  of  forward  displacement  palpable  deformity.  Since  this 
displacement  always  implies  a  ligamentous  rupture,  there  is  left  a  weak 
joint  with  tendency  to  recurrence  of  acute  painful  displacement  upon 
slight  traumatism. 

Rupture  of  the  semilunar  cartilage,  the  usual  injury  when  this  structure 
can  be  felt  projecting  externally  or  when  it  is  driven  internally  (rare),  and 
its  absence  can  be  noted,  exhibits  the  symptomatology  described  under 
subluxation. 

The  after  effects  of  these  injuries  are  recurring  attacks  of  neuralgic 
pain  associated  with  a  joint  subject  to  synovial  eft'usion  from  overuse  or 
slight  strain.  In  some  instances  there  develops  a  chronic  synovitis  with 
effusion,  capsular  thickening,  creaking,  and  recurring  attacks  of  sudden 
fixation. 

Rupture  of  the  ligamentum  patellce  exhibits  the  disability  of  fractured 
patella  with  a  break  in  the  continuity  of  the  ligament  detected  by  direct 
examination.  Unless  the  rupture  be  close  to  the  tibial  attachment  of  the 
ligament,  there  will  be  effusion  of  blood  into  the  joint. 

Rupture  of  the  quadriceps  tendon,  characterized  by  severe  pain,  partial 
or  complete  loss  of  extending  power,  local  tenderness,  and  a  break  in  the 
continuity  of  the  tendon,  is  readily  felt  by  palpation,  even  though  it  be 
obscured  by  the  free  subcutaneous  hemorrhage  common  in  this  injury. 

Rupture  of  the  crucial  ligaments,  incident  to  either  hyperextension  or 
rotation,  often  associated  wnth  a  tearing  loose  of  a  bony  fragment  from 
the  femur,  is  characterized  by  severe  pain  and  rapid  blood  effusion  into 
the  joint.  Preternatural  mobility  of  the  tibia  on  the  femur  in  an  antero- 
posterior direction,  usually  associated  with  lateral  wobbling,  is  character- 
istic, as  is  also  the  finding  of  a  loose  bony  fragment  in  the  joint  by  the 
a;-rays. 

Contusion  or  tear  of  the  alar  ligaments,  the  ligamenta  mucosa,  or  the 
synovial  fringes,  incident  to  trauma  not  sufficiently  severe  to  cause  rup- 
ture of  the  stronger  ligaments,  is  characterized  by  the  tenderness,  pain, 
disability,  and  joint  effusion  typical  of  contusion  or  sprain.  As  a  secpel 
to  such  injury,  convalescence  is  slow  and  incomplete.  Either  free  or 
attached  bodies  are  prone  to  develop;  these  may  be  fatty,  fibrous,  car- 
tilaginous, or  even  calcareous. 

Osteoarthritis  of  the  Knee.- — Osteoarthritis  of  the  knee,  either  in  its 
hypertrophic  or  atrophic  form,  may  be  limited  to  the  joint,  but  is  usually 
associated  with  similar  lesions  of  other  joints.  The  atrophic  form, 
usually  affecting  women  of  middle  age  or  before  it,  exhibits  the  gradual 
onset,  pronounced  muscular  atrophy,  spindle-shaped  swelling,  and  joint 
creaking  characteristic  of  the  affection.  The  hypertrophic  form,  occur- 
ring frecjuently  at  a  more  advanced  age,  may  attack  the  knee  alone  and 
remain  limited  to  it.  Slow  progression  (years)  of  symptoms,  slight  or 
absent  exudation,  obvious  bony  and  cartilaginous  deformity,  and  absence 
of  constitutional  symptoms  are  suggestive  symptoms,  x^bsolute  diag- 
nosis can  be  made  by  the  .T-rays. 

In  its  chronic  form  hemophilia  is  characterized  by  recurrent  attacks 


600 


THE  LOWER   EXTREMITY 


of  intra-articular  hemorrhage  followed  by  extensive  destruction  of  joint 
surfaces,  producing  ultimately  the  changes  characteristic  of  advanced 
osteoarthritis.  In  the  absence  of  the  hemophilic  history  or  aspiration 
of  blood  from  the  joint,  the  distinction  from  tuberculosis  or  osteoarthritis 
of  other  origin  may  be  difficult. 

Fractures  about  the  Knee,— The  break  may  involve  the  patella,  the 
epiphyses  of  the  femur  or  tibia,  or  their  condyles  or  tuberosities. 

Fracture  of  the  'patella,  an  affection  of  active  adult  males,  is  usually 
incident  to  a  sudden  violent  pull  of  the  quadriceps  tendon  and  is 
transverse.  \^Tien  caused  by  direct  violence,  the  fracture  lines  are 
often  multiple,  running  in  any  direction. 

The  characteristic  symptoms  are  a  sudden  and  painful  loss  of  the  power 
of  extending  the  leg,  following  a  blow,  or  a  muscular  effort  in  which 


Fig.  4031 


Fig.  404 


Fig.  403. — Transverse  fracture  of  patella,  in  adult  male,  ununited  six  months  after  injury. 
Example  of  usual  type  and  about  average  amount  of  separation  of  fragments.  Note  forward 
and  downward  tilting  of  lower  fragment  in  this  case. 

Fig.  404. — Fracture  of  patella  similar  in  type  to  preceding  one,  in  a  male,  aged  twenty-two  years, 
six  weeks  after  open  operation  and  wiring.  Radiograph  indicates  some  bony  union  between  deeper 
portions   of  fragments. 


1  Figs.  403  to  406.  Fractures  of  the  patella.  Outline  drawings  from  radiographs  by  Dr.  H.  K, 
Pancoast  in  collection  of  University  Hospital  i-ray  Laboratory;  patients  referred  by  or  from  services 
of  Drs.  Wood,  Frazier,  and  Martin. 


THE  KNEE 


601 


Fig.  405 


Fig.  40G 


Fig.  405. — Refracture  in  same  case  as  Fig.  404,  resulting  from  a  fall  about  six  weeks  later. 
Radiograph  suggests  partial  untwisting  of  wire  and  loop  unbroken  and  still  tending  to  prevent 
wide  displacement.     (Open  wound  rendered  fracture  compound,  and  septic  arthritis  followed.) 

Fig.  406. — Comminuted  fracture  of  patella,  in  adult  male,  result  of  direct  violence — fall  from  a 
ladder,  striking  on  knee.  Radiograph  three  hours  after  injury.  Clinical  diagnosis  of  fracture  and 
variety  not  difficult,  but  x-rays  important  to  determine  amount  of  comminution  and  separation 
before  operation,  and  also  advisability  of  latter. 


something  is  felt  to  have  broken.  If  the  fracture  be  complete  and  the 
fibrous  expansion  to  either  side  of  the  patella  be  torn,  there  is  marked 
separation  of  the  fragments,  and  a  groove  which  is  widened  by  flexion 
can  be  felt  between  them.  The  amount  of  separation  depends  upon 
the  extent  to  which  the  lateral  aponeurosis  of  the  quadriceps  muscle  is 
involved.  There  is  an  immediate  blood  effusion  into  the  joint,  often 
also  into  the  prepatellar  bursa. 

Fractures  due  to  direct  violence  are  evidenced  by  skin  ecchymoses 
at  the  point  of  impact  and  usually  by  comminution. 

The  diagnosis  in  case  of  wide  separation  is  readily  made.  When  the 
separation  is  slight,  owing  to  preservation  of  the  ligamentous  attach- 
ments, it  may  depend  upon  eliciting  preternatural  mobility,  the  patella 
being  grasped  from  above  and  below  and  the  parts  being  pressed 
alternately  from  side  to  side. 

Blood  effusion  into  the  prepatellar  bursa  may  give  the  examining 
finger   an   area   of   lessened   resistance   and   a  crepitation   simulating 


602 


THE  LOWER  EXTREMITY 


fracture.  The  patella  is  firm  throughout,  and  flexion  of  the  leg  does 
not  increase  the  apparent  space. 

Fracture  of  the  femur  near  the  knee-joint,  or  involving  it,  may  be  condy- 
lar or  epiphyseal.  These  fractures  are  incident  to  great  force,  usually 
indirect,  are  often  compound,  and,  except  the  epiphyseal,  involve  the 
joint.  They  are  frequently  complicated  by  lesions  of  the  vessels  and 
nerves  of  the  popliteal  space. 

Fracture  of  the  condyles  is  due  to  direct  or  indirect  force,  the  shaft 
of  the  femur  in  the  latter  instance  acting  as  a  down-driven  wedge.  It 
always  involves  the  joint,  hence  is  attended  by  rapid  swelling  from  blood 
effusion. 

One  condyle  alone  may  be  involved.  Usually  the  break  is  inter- 
condyloid  and  communicates  with  a  transverse  fracture  above.  The 
fragments  are  displaced  outward  and  upward,  and,  unless  the  swelling 
be  excessive  and  the  tenderness  prohibitive,  crepitus  and  preternatural 
mobility  are  readily  elicited. 

The  x-rays  are  necessary  for  a  complete  diagnosis,  since  displacement 
of  the  articular  surfaces  may  be  pronounced,  and  yet  not  readily 
demonstrable  by  any  other  means. 


Fig.  4071 


Separation  of  lower  epiphysis  of  femur,  with  complete  anterior  and  upward  displacement,  in  a 
boy,  aged  eleven  years.  Caused  by  foot  being  caught  in  spokes  of  a  wagon  wheel  while  '  'stealing 
a  ride."     Lateral  view,  before  reduction. 

1  Fig.  407.  Outline  drawing  from  radiograph  by  Dr.  H.  K.  Pancoast  in  collection  of  University 
Hospital  a-ray  Laboratory;  patient  referred  from  service  of  Dr.  Martin. 


THE  KNEE 


603 


Fracture  of  one  condyle  may  be  unattended  by  either  undue  mobility 
or  deformity,  joint  effusion,  persistent  local  tenderness,  and  disability 
being  the  only  obvious  symptoms. 

Fracture  of  the  adductor  tubercle  (rare)  is  characterized  by  local  per- 
sistent tenderness  and  bony  outgrowth.  The  diagnosis  is  made  by  the 
x-rays. 

Separation  of  the  lower  femoral  epiphysis,  usually  observed  before  the 
tenth  year,  impossible  after  the  twentieth,  is  characterized  by  preternatural 
mobility  and  a  deformity  which   may  strongly  suggest  luxation.     The 


Fig.  4081 


Fig.  409 


Fig.  408. — Example  of  a  so-called  "sprain  fracture,"  in  a  male,  aged  thirty-seven  years  A 
small,  scale-like  fragment  has  been  separated  from  the  outer  surface  of  the  head  of  the  tibia,  probably 
representing  tearing  away  of  attachment  of  lateral  ligament.  Injury  caused  by  wheel  of  a  wagon 
passmg  over  the  region  of  the  patient's  knee. 

Fig.  409. — Fracture  of  head  of  tibia,  comparable  to  a  fracture  of  both  tuberosities,  or  a  so-called 
"T-fracture,"  but  without  separation  of  fragments  or  widening  of  joint.  Radiograph  suggests  more 
or  less  impaction.  Exact  clinical  diagnosis  of  such  fractures  difficult,  and  x-rays  of  great  assistance. 
View  represented  nearlj"^  but  not  directly  anteroposterior.  An  important  feature  is  involvement  of 
the  joint.     Male,  aged  sixty  years. 


1  Figs.  408  to  412.  Fractures  of  the  bones  of  the  leg  at  the  knee.  Outline  drawings  from  radio- 
graphs by  Dr.  H.  K.  Pancoast  in  collection  of  University  Hospital  i-ray  Laboratory;  patients 
referred  by  or  from  services  of  Drs.  White  and  Wood. 


604  THE  LOWER  EXTREMITY 

Fig.  410  Fig.  411 


Fig.  410. — Fracture  of  head  of  tibia,  similar  in  type  to  preceding  one,  but  presenting  more  com- 
minution, appreciable  separation,  and  slight  widening  of  joint.  Also  an  additional  fracture  through 
neck  of  fibula.     Patient  (female,  aged  fifty-four  years)  was  struck  by  a  trolley  car. 

Fig.  411. — Fracture  of  head  of  tibia  and  neck  of  fibula,  in  female,  aged  fifty-eight  years.  Peculiar 
type,  but  presenting  some  features  of  preceding  case.  Not  essentially  a  fracture  of  both  tuberositiei?, 
but  primarily  a  separate  break  through  upper  portion  of  shaft,  which  reaches  outer  surface  of 
bone,  whence  the  line  is  practically  continuous  with  that  of  fracture  through  middle  of  outer  tuber- 
osity. 

lower  end  of  the  upper  fragment  usually  projects  in  the  popliteal  space, 
the  lower  fragment  being  carried  forward  and  often  so  rotated  that  its 
broken  surface  is  in  apposition  with  the  shaft  of  the  diaphysis.  The 
adductor  tubercle  remains  attached  to  the  shaft  and  the  tibia  retains 
its  normal  relations  to  the  condyles.  The  age  of  incidence,  the  com- 
paratively smooth,  broken  surface  when  this  can  be  felt,  possibly  the 
moist  crepitus,  and  the  x-rays  establish  the  diagnosis. 

Fracture  of  the  upper  end  of  the  tibia,  incident  to  direct  violence  or  jar 
in  the  long  axis  of  the  bone  may  be  transverse  or  longitudinal,  without 
involving  the  joint.  Usually  the  line  of  fracture  runs  directly  into  the 
joint  and  results  in  separation  of  one  or  both  tuberosities. 

In  addition  to  the  hemarthrosis,  disability,  preternatural  mobility, 
and  local  tenderness  exaggerated  lateral  mobility  is  highly  character- 
istic, the  rocking  being  most  marked  in  the  direction  of  the  fractured 
tuberosity.     Diagnosis  should,  however,  be  made  by  the  x-rays.     This 


THE  KNEE 


605 


Fig.  412 


Fracture  of  head  of  tibia  with  distinct  impaction  and  some  separation  of  lateral  fragment 
representing  tuberosities,  causing  slight  widening  of  joint.  Also  a  fracture  of  upper  portion  of 
shaft  of  fibula.     Caused  by  a  jump  from  a  second-story  window.     Female,  aged  forty-two  years. 


frequently  shows  fissures  in  the  absence  of  the  cardinal  symptoms  of 
fracture. 

Separation  of  the  upper  tibial  epiphysis  (rare),  possible  up  to  the 
twentieth  year,  is  observed  mainly  in  males.  It  is  characterized  by  dis- 
placement of  the  leg  in  any  direction,  except  backward,  the  tuberosities 
of  the  bone  maintaining  their  normal  relation  to  the  joint.  The  a-rays 
are  diagnostic  though  the  seat  of  fracture,  transverse  direction,  and 
moist  crepitus  may  be  suggestive. 

Diagnosis  is  based  upon  the  obvious  deformity  and  its  seat. 

Separation  of  the  tubercle  of  the  tibia  incident  to  muscular  action,  and 
observed  usually  in  athletic  boys,  is  characterized  by  tenderness,  pain 
and  sw^ellinoj  in  the  region  of  the  tubercle,  and  bv  the  finding  of  the 
movable  bone  fragments  if  the  separation  be  complete. 

In  the  absence  of  complete  separation,  the  persistence  of  tenderness, 
pain,  disability,  and  bone  swelling  are  suggestive  symptoms  which  may 
be  corroborated  by  the  ar-rays.  As  a  consequence  of  partial  fracture 
there  may  be  a  bony  outgrowth  in  this  region. 


606  THE  LOWER  EXTREMITY 

Dislocation  of  the  Knee-joint.- — The  tibia  may  be  displaced  from  the 
femur  in  any.  direction,  usually  as  the  result  of  very  great  violence, 
readily  recognized  by  the  obvious  and  palpable  deformity. 

The  patella  may  be  dislocated  either  outward  or  inward,  or  may  be 
rotated  on  its  vertical  axis  through  a  quarter  or  half  circle. 

The  diagnosis  is  readily  made  by  inspection  and  palpation.  The 
outward  luxation  is  the  commoner  form  and  may  occur  from  muscular 
action,  doubtless  predisposed  to  by  congenital  formation,  the  outer  lip 
of  the  intercondyloid  notch  being  defective. 

Weakness  of  the  vastus  internus  muscle,  genu  valgum,  and  chronic 
arthritis  predispose  to  habitual  luxation. 

Luxation  of  the  fibula  from  the  tibia  (rare),  usually  forward  and  out- 
ward, is  characterized  by  a  depression  at  the  usual  site  of  the  fibular 
head  and  the  presence  of  this  bony  prominence  in  an  abnormal  position. 

Subluxation  of  the  semilunar  cartilage,  an  injury  to  which  vigorous 
young  men  are  subject,  is  usually  due  to  violent  outward  rotation  of  the 
leg  on  the  thigh  when  the  limb  is  in  a  position  of  slight  flexion.  Twists 
such  as  occur  in  running  jumping,  skating,  or  even  dancing,  are  common 
causes.     The  inner  cartilage  is  the  one  customarily  involved  (see  p.  598). 

Periarticular  Inflammation. — The  skin  of  the  knee,  particularly  on 
its  anterior  surface,  is  subject  to  abrasion,  furuncle,  abscess,  and  to  the 
secondary  and  tertiary  lesions  of  syphilis.  These  lesions  conform  to 
type.  Those  of  acute  inflammatory  origin  not  infrequently  involve  the 
patellar  bursa  in  a  suppurative  inflammation  followed,  in  the  absence 
of  appropriate  treatment,  by  persistent  sinus  formation. 

Secondary  lesions  of  syphilis  are  always  attended  by  other  corroborative 
signs  of  the  disease.  Dermal  and  subdermal  gummata  exliibit  a  special 
predilection  for  the  soft  parts  overlying  the  patella.  Indeed,  they  not 
infrequently  start  in  this  bone.  They  are  characterized  by  painless 
infiltration  which  slowly  (weeks)  breaks  down  into  a  circular  ulcer  with 
a  bacon-like  base. 

Acute  inflammation  of  the  popliteal  space,  unless  it  be  caused  by  a 
wound,  is  usually  due  to  adenitis,  secondary  to  an  infection  of  the  foot 
and  leg  which  may  have  been  so  slight  as  to  escape  notice,  or  to  a  similar 
condition  of  the  glands  incident  to  subcutaneous  hemorrhage  or  to  over- 
use. Tenderness,  pain  radiating  down  the  leg,  slight  sense  of  fulness  in 
the  popliteal  space,  often  the  detection  of  a  tender,  swollen  gland  of  small 
size  are  the  symptoms  noted.  Suppuration  is  characterized  by  its  usual 
local  and  constitutional  signs. 

In  some  cases  these  symptoms  are  but  slightly  marked,  the  pus 
burrowing  from  the  popliteal  space  along  the  course  of  the  bloodvessels 
and  forming  collections  in  the  intermuscular  septa  of  both  the  anterior 
and  the  posterior  tibial  group.  The  symptoms  are  expressed  in  the  leg 
as  fluctuating  swellings  attended  with  moderate  disability,  some  pain, 
and  a  low  grade  of  sepsis. 

Acute  thrombophlebitis,  either  suppurative  or  simple,  is  frequently 
developed  in  dilated  subcutaneous  veins  about  the  knee-joint,  particu- 
larly those  of  the  long  saphenous  group  overlying  the  inner  condyle. 


THE  KNEE 


607 


Induration  along  the  vein  is  characteristic.  In  suppurative  cases  it  is 
shortly  obscured  by  the  inflammatory  swelling.  Because  of  the  move- 
ments of  the  joint,  thrombi  formed  about  the  knee  are  particularly 
likely  to  be  carried  into  the  general  circulation. 

Thrombosis  of  the  popliteal  vein,  expressed  by  tenderness  and  indura- 
tion along  the  course  of  this  vessel,  engorgement  of  the  external  popli- 
teal vein,  edema  of  the  foot  and  leg,  usually  by  constitutional  symptoms 
of  infection,  which  in  the  case  of  septic  thrombosis  become  of  high  grade 
and  are  accompanied  by  the  local  features  of  acute  phlegmon. 

Bursitis. — Of  the  many  bursse  about  the  knee-joint  the  prepatellar  is 
the  one  most  frequently  involved  in  both  acute  and  chronic  inflamma- 
tion. The  infrapatellar,  the  pretibial,  and  the  bursa  placed  between  the 
gastrocnemius  muscle  and  the  semimembranosus  tendon  are  affected 


Fig.  413 


Chronic  prepatellar  bursitis.  (Housemaid's  knee.)  Twenty  years'  duration.  Swelling  began 
one  week  after  punctured  wound.  Knee-joint  normal.  Swelling  situated  in  front  of  patella. 
Fibroid  thickening  of  walls  of  bursa.     Fluctuation  present.     Skin  normal.     (Blockley  Out-ward.) 


next  in  order  of  frequency,  usually  in  the  form  of  a  chronic  inflam- 
mation expressed  by  serous  effusion,  the  dominant  symptom  being  the 
presence  of  a  fluctuating  tumor. 

Acute  prepatellar  bursitis,  secondary  to  trauma,  or  an  overlying 
suppurating  skin  lesion,  is  marked  by  fluctuating  swelling  beneath  the 
skin,  between  it  and  the  anterior  surface  of  the  patella. 

Blood  effusion  immediately  after  trauma  often  gives  a  crepitation 
suggestive  of  fracture,  but  distinctly  softer.  Serous  effusion  is  char- 
acterized by  the  absence  of  inflammatory  symptoms.  Purulent  involve- 
ment exhibits  characteristic  local  and  general  symptoms  of  suppuration, 
with  often  an  edematous  swelling  so  widespread  that  involvement  of 
the  joint  is  suggested. 


608  THE  LOWER  EXTREMITY 

A  serous  exudate  into  the  joint  may  occur  as  a  complication,  but 
arthritis  is  readily  excluded  by  free  movements  and  absence  of  true 
joint  tenderness. 

Chronic  prepatellar  bursitis  incident  to  slight  repeated  trauma,  as  from 
kneeling,  or  consequent  on  failure  to  properly  treat  an  acute  inflammation, 
is  characterized  mainly  by  a  persistent  fluctuating  tumor  in  the  position 
of  the  bursse.     Greatly  thickened  walls  may  simulate  a  solid  tumor. 

Tuberculous  prepatellar  bursitis,  occurring  independently  of  patellar 
involvement,  exhibiting  more  inflammatory  thickening  and  greater 
sensitiveness  than  that  incident  to  the  non-tuberculous  form  of  involve- 
ment, can  be  diagnosticated  in  the  absence  of  other  tuberculous  lesions 
only  by  excision  and  microscopic  examination,  or  the  application  of 
the  tuberculin  test. 

Infrapatellar  bursitis  is  marked  by  a  fluctuating  swelling  appearing 
to  either  side  of  the  ligamentum  patellae  and  by  pain  during  the  act  of 
extension.  The  cushions  of  fat  lying  in  this  region  sometimes  become 
hypertrophied  and  closely  simulate  a  bursitis.  Through  fluctuation 
cannot,  however,  be  elicited. 

Pretibial  bursitis  forms  a  swelling  in  front  of  the  tibial  spine  between  it 
and  the  skin. 

Gastrocnemius-semimembranosus  bursitis  causes  a  fluctuating  swelling 
in  the  popliteal  space.  Normally  the  U-shaped  bursa  may  be  multi- 
locular,  and  in  muscular  subjects  not  infrequently  communicates  with 
the  joint  or  with  a  second  bursa,  which  in  turn  has  a  joint  communi- 
cation. An  effusion  into  the  bursa  secondary  to  overuse,  trauma,  or 
without  obvious  cause,  forms  a  tumor  at  first  to  the  inner  side  of  the 
popliteal  space,  later  filling  the  greater  portion  of  this  space.  It  is  tense 
and  prominent  on  extension  of  the  knee,  is  deeply  attached  to  the  flexor 
tendons,  fluctuates,  becoming  soft  on  flexion,  and  sometimes  exhibits 
the  quality  of  reducibility  into  the  joint.  Occasionally  crepitation  due 
to  rice-like  bodies  may  be  perceived. 

Mechanical  limitation  of  flexion,  weakness  of  the  knee-joint,  and 
pain  are  the  dominant  symptoms.  Later  there  may  follow  edema  from 
pressure  on  the  bloodvessels.     The  affection  may  be  bilateral. 

The  distinction  from  cold  abscess  and  from  lipoma  may  be  difficult. 
The  former  has  usually  definite  joint  symptoms  of  slowly  progressive 
development.  Nor  is  the  fluctuating  tumor  formed  by  it  likely  to  be  so 
definitely  outlined.  If  of  bone  origin,  which  is  usual,  the  ic-rays  should 
demonstrate  osseous  lesion.  This  may  be  so  slight  as  to  show  no  clear 
picture,  and  the  abscess  may  have  formed  independently  of  the  joint. 
The  differential  diagnosis  has  often  been  made  only  at  operation. 

Biceps  Bursitis. — Acute  or  chronic  inflammation  of  the  bursa  lying 
between  the  biceps  tendon  and  the  external  lateral  ligament,  because 
of  the  proximity  of  the  peroneal  nerve,  may  be  attended  by  severe  pain 
radiating  down  the  leg.  The  swelling  lies  over  the  head  of  the  tibia,  and 
in  its  development  extends  backward  toward  the  popliteal  space. 

Popliteal  bursitis  forms  a  cystic  swelling  primarily  located  in  the  lower 
outer  part  of  the  popliteal  space. 


THE  KNEE 


609 


Aneurysm  of  the  Popliteal  Artery. — Aneurysm  of  the  popliteal 
artery,  a  favorite  seat,  common  in  hard-working,  hard-drinking  syphil- 
itics,  is  usually  characterized  by  some  limitation  of  the  joint  movement 
and  pain  in  the  popliteal  space  radiating  downward  into  the  leg.  Later 
there  develops  a  tumor  usually  with  an  expansile  pulsation,  bruit,  and 
thrill.  The  effect  upon  the  size  of  the  tumor  of  pressure  upon  the  artery 
above  and  below  is  the  most  characteristic  symptom.  Acute  inflam- 
matory phenomena  may  develop,  the  symptoms  then  closely  resembling 
abscess  or  bursitis. 


Fig.  414 


Subacute  serofibrinous  effusion  into  the  knee-joint.  Duration,  six  weeks;  in  patient  with  subacute 
total  gonorrheal  urethritis.  Fluctuating  swelling  confined  to  limits  of  joint  cavity.  Obliteration 
of  normal  depressions  in  front  of  knee.  Slight  enlargement  of  superficial  veins.  Skin  normal  in 
color.     Pain  and  disability  not  pronounced. 


Inflammation  of  the  Knee-joint. — Acute  Traumatic  Arthritis. — Acute 
traumatic  arthritis,  incident  to  contusion,  sprain,  or  fracture,  is  charac- 
terized by  a  rapid  effusion  into  the  joint  (minutes  or  hours,  if  hemor- 
rhage), evidenced  by  floating  of  the  patella  and  fulness  about  its  sides, 
pain,  tenderness,  and  disability.  Under  rest  the  symptoms  usually 
promptly  subside.  Their  continuance  or  aggravation  under  use  suggest 
an  uncured  fracture  which  may  be  a  fissure  without  displacement,  injury 
to  the  semilunar  cartilages,  thickening  of  the  synovial  fringes,  or  liga- 
mentous or  muscular  relaxation  of  such  nature  and  extent  as  to  put  the 
joint  to  mechanical  disadvantage  when  used.  Persistent  aggravation 
of  symptoms  after  slight  traumatism  adequately  treated  should  in  young 
people  suggest  the  possibility  of  beginning  tuberculosis. 
39 


610  THE  LOWER  EXTREMITY 

Following  fracture  of  the  shaft  of  the  femur,  particularly  its  lower 
third,  there  is  very  commonly  observed  a  synovial  effusion  into  the  knee- 
joint  of  sufficient  extent  to  float  the  patella.  In  young  people  it  subsides 
promptly. 

An  acute  rapid  effusion  into  the  knee-joint  from  what  would  usually 
be  inadequate  trauma  is  typical  of  hemophilia.  A  suggestive  history 
usually  can  be  elicited.  The  diagnosis  has  often  not  been  suspected 
until  aspiration  demonstrated  a  joint  cavity  filled  with  blood. 

The  joint  effusion  may  be  serous,  serofibrinous,  or  suppurative,  the 
first  attended  by  practically  no  constitutional  symptoms;  the  second  by 
those  of  moderate  severity,  usually  incident  to  the  severe  pain  char- 
acteristic of  it;  the  third  by  the  local  and  general  evidences  of  profound 
intoxication. 

Gonorrhea  and  rheumatism  are  the  usual  systemic  causes  of  acute 
inflammation  of  the  knee-joint. 

Gonococcal  Arthritis. — Gonococcal  arthritis  in  its  serous  form  is 
attended  with  rapid  and  usually  painful  swelling,  not  infrequently  in- 
volving both  knees.  The  patella  is  usually  floated  up  so  wide  of  the 
femur  that  it  cannot  be  tapped  against  it.  Fluctuation  is  obvious. 
The  diagnosis  is  based  upon  the  finding  elsewhere  of  a  focus  of  gonor- 
rheal infection  and  an  examination  of  the  joint  contents. 

This  serous  exudate  may  exhibit  a  tendency  to  recur  incident  to  slight 
relighting  of  long  standing,  often  unrecognized  urethral  infection.  The 
recurrences  are  marked  mainly  by  effusion,  the  patients  exhibiting  an 
absence  of  pain  and  a  functional  ability  which  are  considered  char- 
acteristic of  the  tabetic  joint. 

The  plastic  form  of  gonorrheal  arthritis  is  attended  by  slight  intra- 
articular exudate,  dense  periarticular  infiltration,  harassing  pain,  rapid 
muscle  atrophy,  constitutional  symptoms  of  moderate  severity,  and 
partial  or  complete  ankylosis. 

The  suppurative  form  (rare)  exhibits  the  local  and  general  symptoms 
of  pus-formation.  Early  diagnosis  is  best  made  by  aspiration  or  incision 
into  the  joint,  and  examination  of  its  contents. 

Acute  Rheumatic  Arthritis. — Acute  rheumatic  arthritis  is  character- 
ized by  the  rapid  onset  of  a  serous  exudate.  It  is  usually  extremely 
painful  and  is  attended  with  other  symptoms  of  rheumatic  infection,  i.  e., 
migratory  character  of  the  joint  involvement,  moderate  fever,  rapid 
pulse,  and  copious  acid  sweats.  The  diagnosis,  however,  should  not  be 
formulated  until  other  causes  for  acute  arthritis  have  been  excluded. 

Exanthematous,  influenzal,  typhoidal,  pneumonic,  and  pyemic  inflam- 
mations are  recognized  as  such  in  accordance  with  their  association 
with  the  major  disease. 

Chronic  Traumatic  Arthritis. — Chronic  traumatic  arthritis,  a  sequel 
of  acute  traumat'sra,  unless  it  be  definitely  associated  with  the  symp- 
toms of  loose  cartilage,  free  body,  or  relaxed  ligaments,  can  be  recog- 
nized as  traumatic  only  after  careful  exclusion  of  infecting  causes,  a 
distinct  history  of  adequate  trauma,  and  an  estimation  as  to  the  curative 
effects  of  rest. 


THE  KNEE 


611 


Any  of  the  forms  of  acute  infectious  arthritis  may  become  chronic,  this 
being  particularly  true  of  a  gonococcal  infection. 

The  two  infections  which  begin  insidiously  and  are  chronic  from  the 
first  are  tuberculosis  and  syphilis. 

Tuberculosis  of  the  Knee. — Tuberculosis  of  the  knee,  beginning,  as  a 
rule,  m  the  femoral  or  tibial  epiphysis,  commonest  in  children  and  adol- 
escents, is  occasionally  seen  in  young  adults,  exceptionally  at  a  more 
advanced  age. 

Fig.  415 


Typical  soft,  non-adherent,  rovmded,  grouped  scara  of  a  tertiary  skin  syphilide.     Duration,  years. 

It  is  characterized  by  apparent  causelessness,  insidious  onset,  and 
slow  progression.  Intermitting  limp  is  usually  the  first  symptom  to 
attract  attention,  and  is  associated  with  tenderness  and  limitation  of 
motion  due  to  muscular  spasm,  neither  extreme  extension  nor  complete 
flexion  being  possible.  Tenderness  varies  in  position  in  accordance 
with  the  seat  of  primary  infection.  Swelling  is  easily  demonstrable 
because  of  the  accessibility  of  the  joint.  There  is  muscular  atrophy 
most  marked  in  the  extensor  region. 

Sometimes  there  is  severe  pain  which  may  be  paroxysmal  or  constant. 
Exceptionally  there  is  a  subacute  onset  which  simulates  acute  infection. 


612 


THE  LOWER  EXTREMITY 


In  its  further  development  the  affection  is  characterized  by  an  elastic, 
at  times  hard,  swelling  which  obscures  the  outlines  of  the  joint;  muscular 
atrophy  and  contracture  which  may  produce  a  partial  backward  luxa- 
tion of  the  tibia  upon  the  femur,  often  associated  with  outward  rotation 
and  genu  valgum;  at  times  slight  lengthening  of  the  bone  involved 

from  epiphyseal  irritation;  usually 
Fig-  416  shortening  incident  to  bone  de- 

struction   followed    by    abscess 
formation. 

Early  diagnosis  is  based  upon 
the  persistence  and  the  steady 
progression  of  an  apparently 
causeless  chronic  inflammation  in 
the  knee-joint  of  a  child.  The 
exact  seat  of  invasion  may  be 
shown  by  the  a:-rays  before  the 
joint  is  directly  involved. 

Associated  tuberculous  lesions 
elsewhere  and  the  positive  results 
of  the  tuberculin  test  are  diag- 
nostic aids. 

The  distinction  between  a  tu- 
berculous knee  and  one  that  is 
contused  or  sprained  is  based 
upon  the  history  of  adequate  trau- 
matism and  the  prompt  and  com- 
plete disappearance  of  symptoms 
of  contusion  or  sprain  under 
appropriate  treatment.  Early 
active  and  persistent  use  of  a 
contused  knee  may  result  in  a 
condition  of  chronic  synovitis 
which  closely  simulates  local  tu- 
berculosis. 

Sarcoma     involving     the     ex- 
tremity of  the  femur  or  tibia  is 
at  first   characterized   chiefly  by 
severe  localized  pain,  which  may 
be  referred  to  the  knee.     When  the  tumor  appears  it  is  usually  charac- 
terized by  a  growth  far  more  rapid  than  that  observed  in  local  tubercu- 
losis.    In  the  case  of  sarcoma  the  a;-rays  may  be  diagnostic. 

Persistent  pain,  unrelieved  by  treatment  appropriate  to  tuberculous 
gonitis,  with  localization  of  bone  lesion  by  the  x-rays  should  suggest  a 
differential  diagnosis  by  early  operation. 

Syphilitic  Arthritis  of  the  Knee. — Syphilitic  arthritis  of  the  knee,  in 
its  tertiary  chronic  form,  so  closely  simulates  that  due  to  tuberculosis 
that  a  diagnosis  must  depend  upon  the  history,  the  reaction,  the  treat- 
ment,  and   the   tuberculin   test.      The  syphilitic  affection   is   rare   in 


Tabetic  arthropathy  (Charcot's  disease)  of 
the  knee-joint.  Insane  patient  with  locomotor 
ataxia.  Relaxation  of  ligaments.  Effusion 
and  numerous  loose  bodies  in  joint.  Absorption 
of  articular  surfaces.  Functionally  useless,  pain- 
less joint.     (Carnett.) 


THE  KNEE  613 

children.  It  usually  begins  in  the  femoral  epiphysis  and  is  exceedingly 
painful. 

Neuropathic  Arthritis  of  the  Knee. — Neuropathic  arthritis  of  the  knee, 
at  times  preceding  other  manifestations  of  ataxia,  is  characterized  by 
the  sudden  and  painless  onset  of  joint  effusion  without  local  or  general 
inflammatory  phenomena,  aside  from  edema  which  may  be  widespread. 
There  is  but  little  disability.  In  its  complete  development  the  affection 
is  characterized  by  gross  deformity,  relaxed  ligaments,  often  subluxation. 

The  large  tumor-like  formation  with  dilated  veins  suggests  in  appear- 
ance sarcoma.  The  absence  of  subjective  symptoms,  the  comparatively 
slight  interference  with  function,  and  the  associated  ataxic  manifestations 
suggest  the  diagnosis. 

Painful  Conditions  of  the  Knee  without  Local  Lesion. — The  so-called 
growing  pains,  common  in  the  knee-joint,  often  marked  after  overuse 
and  doubtless  incident  to  transient  moderate  congestion,  are  unattended 
by  limp,  limitation  of  motion,  joint  effusion,  or  atrophy. 

Pain  may  be  referred  to  the  knee  as  the  result  of  pressure  or  inflam- 
mation of  the  anterior  crural,  obturator,  or  great  sciatic  nerves.  Such 
pain  is  not  limited  to  the  knee. 

Inflammatory  affections  of  the  hip-joint  are  particularly  characterized 
by  reference  of  pain  to  the  knee.  To  a  less  marked  degree  similar 
reference  occurs  in  affections  of  the  kidney,  ureter,  bladder,  prostate,  and 
uterus.  Freedom  and  painlessness  of  movement  suggest  the  reflex 
origin  of  the  pain. 

Neuralgia  of  the  knee-joint  is  characterized  by  pain  and  tenderness 
following  inadequate  trauma,  varying  in  seat,  and  out  of  proportion  to 
the  local  findings.  There  may  be  muscular  fixation,  increase  of  surface 
temperature,  skin  hypersensibility,  and  slight  swelling.  Because  of 
pressure  upon  the  vein,  edema  of  the  leg  is  often  marked.  Diagnosis 
is  based  upon  the  disagreement  of  symptoms  and  signs,  the  absence  of 
muscular  atrophy,  the  negative  findings  of  the  a;-rays  and  exclusion  by 
repeated  careful  examination  for  the  lesions  of  tuberculosis  and  syphilis. 

Such  symptoms  occurring  in  an  hysterical  subject  are  usually  local 
manifestations  of  this  condition. 

Tumors  of  the  Region  of  the  Knee-joint. — Benign  tumors  origi- 
nating in  the  soft  parts  are,  with  the  exception  of  popliteal  lipoma, 
generally  recognized  as  such  only  because  at  the  time  they  come  under 
observation  they  have  been  present  so  long  and  exhibited  such  slow 
growth  that  malignancy  can  be  ruled  out.  When  seen  in  their  early 
development  diagnosis  should  be  made  by  removal  and  microscopic 
examination. 

Lipoma  placed  in  the  popliteal  space  beneath  the  deep  fascia  forms  a 
rounded,  semifluctuating  tumor,  the  distinction  of  which  from  bursitis 
may  be  possible  only  by  exploratory  operation. 

Sarcoma  begins  precisely  as  do  the  benign  tumors.  A  diagnosis  should 
be  made  by  prompt  removal  before  rapidity  of  growth  suggests  the  nature 
of  the  tumor. 

Exostoses  from  the  epiphyseal  line  of  the  femur  or  tibia  are  common. 


614 


THE  LOWER  EXTREMITY 


They  develop  before  puberty,  are  slow  in  growth,  extending  in  a  spur-like 
manner  away  from  the  joint.  They  may  be  hereditary  and  symmetrical. 
They  are  often  of  traumatic  origin.     The  x-rays  are  diagnostic. 

Bone  sarcoma,  having  for  its  seats  of  predilection  the  upper  portion 
of  the  tibial  and  the  lower  portion  of  the  femoral  diaphysis,  usually 
sparing  the  joint  cavity,  may  be  central  or  peripheral  in  origin,  semi- 
benign,  or  highly  malignant.  The  early  diagnosis  is  based  upon  per- 
sistent, often  intense,  sharply  localized  pain,  usually  attributed  to 
rheumatism  and  treated  as  such,  and  particularly  upon  the  findings  of 


Fig.  417 


KJaee-joint  containing  two  loose  bodies,  only  one  of  which  was  demonstrable  by  a-rays.  Chronic 
serous  synovitis  with  repeated  mild  acute  exacerbations.  Loose  bodies  palpably  slipping  around  in 
joint.     (Carnett.) 

the  a^-rays.  When  the  tumor  becomes  manifest  to  palpation  and  inspec- 
tion, its  rapid  growth  is  in  itself  characteristic.  The  vascular  type  may 
give  both  pulsation  and  feeble  bruit. 

Dilatation  of  the  superficial  veins  and  crepitation  from  the  cracking 
of  the  thin  shell  of  overlying  bone  are  late  symptoms. 

The  early  diagnosis  from  tuberculosis  is  suggested  by  the  intensity 
and  persistence  of  the  pain,  the  futility  of  rest  and  extension  in  relieving 
this,  the  negative  evidence  of  the  tuberculin  test,  and  particularly  by  the 
ic-ray  findings. 

Even  a  clear  a;-ray  picture  may  not  satisfactorily  distinguish  a  cyst 


THE  THIGH  615 

or  central  sarcoma  from  inflammatory  affections,  hence,  given  a  lesion 
which  is  non-syphilitic,  the  diagnosis  both  as  to  its  nature  and  its  relative 
malignancy  should  be  made  promptly  by  operation,  which  at  times  must 
be  supplemented  by  microscopic  examination. 

The  rapid  course  and  development  of  tumor  and  the  absence  of 
joint  involvement  are  later  characteristic. 

Loose  Bodies  in  the  Knee-joint. — Unless  such  bodies  can  be  shown 
by  the  x-rays,  or  are  so  placed  that  they  can  be  palpated,  the  diagnosis 
must  be  based  upon  an  otherwise  causeless  chronic  synovitis,  associated 
with  a  recurring  partial  or  complete  locking  of  the  joint  in  the  perform- 
ance of  certain  motions.  Exceptionally  joint  crepitation,  sudden  weak- 
ness causing  falls,  and  synovial  effusion  constitute  sufficient  ground  for 
exploration  of  the  joint,  particularly  in  fat  people  with  well-developed 
subpatellar  fat  pads  and  presumably  redundant  and  fatty  alar  ligaments. 


THE   THIGH. 

Contusions. — Contusions  of  the  thigh  are  attended  by  an  abundant, 
subcutaneous  blood  effusion  which,  because  of  the  loose  dermal  attach- 
ment, may  form  large,  fluctuating  or  semisolid,  crepitating  tumors. 
As  the  result  of  repeated  traumatism  there  may  form  a  persistent  fluctu- 
ating subcutaneous  tumor,  the  contents  of  which  closely  resemble  clear 
or  slightly  blood-stained  synovia. 

Repeated  trauma  or  overuse  causes  a  myositis,  characterized  by 
tenderness,  induration  of  the  muscles  involved,  and  pain  so  severe  on 
use  as  to  be  crippling.  It  is  a  condition  frequently  noticed  in  the 
extensor  muscle  of  football  players. 

Rupture  of  the  Thigh  Muscles. — Rupture  of  the  thigh  muscles,  involving 
particularly  the  adductors  and  extensors,  commonly  observed  in  those 
who  attempt  athletic  feats  without  adequate  training,  is  characterized 
by  sudden,  severe,  crippling  pain  with  local  tenderness  and  palpable 
break  in  continuity  if  the  seat  of  rupture  be  superficial.  Osseous  growth 
may  take  place  at  the  seat  of  rupture;  this  is  particularly  true  of  such 
injuries  of  the  adductors. 

Hernia  of  the  muscle  is  occasionally  observed  in  the  thigh  (see  p.  108). 

Of  the  various  dermal  lesions  furuncle  is  particularly  common  in 
the  region  of  the  hip. 

Varicosity  of  either  the  long  saphenous  vein  or  of  the  lymphatic 
vessels  passing  to  the  glands  lying  in  the  saphenous  opening  may  form 
superficial,  soft,  lobulated  masses  in  this  region  which,  in  the  case  of 
vein  dilatation,  may  give  impulse  on  coughing. 

Psoas  Abscess. — Psoas  abscess,  or  one  of  pelvic  origin,  may  burrow 
downward  beneath  the  thick,  investing  fascia  of  the  thigh,  forming  a 
large  fluctuating  tumor. 

As  in  the  leg,  extensive  intermuscular  or  subcutaneous  pus  accumulation 
may  occur  without  bone  lesion  or  other  obvious  cause;  usually  in  the 
cachectic,  and  characterized  by  moderate  sepsis  of  the  adynamic  type 


616  THE  LOWER  EXTREMITY 

and  local  inflammatory  symptoms  so  slightly  marked  that  fluctuation 
first  leads  to  the  suspicion  of  pus. 

Aneurysm. — Aneurysm,  which  may  spring  from  any  part  of  the 
femoral  artery,  exhibits  some  or  all  of  its  characteristic  features  (see 
p.  99). 

Sciatica. — Sciatica,  common  in  middle-aged  men,  is  characterized  by 
pain,  usually  paroxysmal  and  increased  by  all  movements  which  stretch 
the  nerve,  and  tenderness  on  deep  pressure  over  its  trunk.  The  points 
of  maximum  sensitiveness  are  just  below  the  border  of  the  gluteus  muscle 
midway  between  the  tuber  ischii  and  the  great  trochanter  and  the  mid- 
portion  of  the  popliteal  space.  There  is  usually  associated  muscular 
weakness  with  exaggerated  reflexes.  Bilateral  sciatica  is  usually  indica- 
tive of  spinal  lesion. 

Pain  along  the  sciatic  nerve  is  a  common  and  early  symptom  of 
inflammation  of  the  sacro-iliac  joint.  It  is  also  characteristic  of  myositis, 
follows  trauma,  and  is  a  common  manifestation  of  pressure  from  pelvic 
tumor  or  inflammation.  There  is  usually  in  chronic  cases  a  scoliosis 
with  its  lumbar  convexity  toward  the  affected  side. 

Fracture  of  the  shaft  of  the  femur,  from  direct  or  indirect  violence  or 
muscular  action,  has  for  its  common  seat  the  middle  third,  and  is  usually 
extremely  oblique  from  above  downward  and  forward.  The  break 
may  be  just  below  the  lesser  trochanter  or  above  the  condyles.  There  is 
marked  shortening,  the  lower  fragment  lies  posteriorly,  and  is  usually 
rotated  outward,  the  foot  lying  flat  on  its  side. 

In  the  subtrochanteric  fracture  the  upper  fragment  is  pulled  forward 
by  the  iliopsoas  muscle  and  rotated  outward.  In  the  supracondyloid 
fracture  the  lower  fragment  is  commonly  rotated  backward  by  the  gastroc- 
nemius muscle. 

Complicating  injuries  of  the  bloodvessels,  exceptionally  the  nerves, 
are  not  infrequent  in  these  fractures,  particularly  those  above  the  knee, 
and  should  be  looked  for  in  the  examination 

At  times  the  fracture  of  the  shaft  is  spiral  and  comminuted,  a  long, 
wedge-shaped  portion  of  bone  being  entirely  separated  from  the  two 
main  fragments. 

In  children  the  fracture  may  be  transverse  and  subperiosteal,  in  which 
case  there  may  be  little  or  no  deformity.  Green-stick  fracture  is  also  not 
uncommon  in  them. 

The  diagnosis  of  fracture  of  the  femur,  if  it  be  complete,  is  usually  made 
by  inspection.  The  outward  rotation  of  the  leg  and  the  obvious  shorten- 
ing, often  angulation,  combined  with  absolute  disability  indicate  the 
nature  of  the  lesion. 

The  measurements  for  shortening  are  taken  on  each  side  from  the 
anterior  superior  spine  of  the  ilium  to  the  internal  malleolus,  the  legs 
and  thighs  occupying  the  same  relative  position  to  the  midline  of  the 
body  in  regard  to  flexion,  rotation,  and  abduction.  A  second  measure- 
ment from  the  top  of  the  trochanter  to  the  external  malleolus  should 
be  taken  and  should  show  the  same  amount  of  shortening  when  this  is 
dependent  upon  overlapping  of  the  bones  of  the  femur. 


THE  THIGH 


617 


Preternatural  mobility  is  easily  elicited,  crepitus  may  be  wanting 
because  of  interposition  of  muscular  tissue. 

Acute  osteomyelitis  of  the  femoral  shaft,  having  for  its  seat  of  predilection 
the  spongy  tissue  at  either  end  of  the  diaphysis,  occurring  most  frequently 
in  boys  and  often  incident  to  slight  trauma  or  chilling,  exhibits  character- 
istic symptoms  of  hyperacute  infection,  severe  pain,  total  loss  of  function, 
tenderness  on  deep  pressure,  and  shortly  edematous  swelling  of  the 
entire  circumference  of  the  thigh  at  the  seat  of  involvement.  The  early 
diagnosis  is  made  by  operation,  the  .r-rays  not  being  helpful  at  this  time. 

Necrosis,  sinus  formation,  sequestration,  are  late  developments  often 
attended  by  pronounced  permanent  deformity. 

Chronic  osteomyelitis,  usually  incident  to  tuberculosis  or  syphilis, 
often  following  an  acute  attack,  sometimes  chronic  from  the  first  even 


Fig.  418 


Pedunculated  fibrolipoma  of  thigh.     Fifteen  years'  duration.     Surface  irregular.     Skin  normal 
and  slightly  movable.     Unevenly  firm  in  consistency.     (Carnett.) 


though  incident  to  staphylococcic  infection,  is  evidenced  by  deep  and 
persistent  pain  and  tenderness,  with  moderate  disability,  slight  con- 
stitutional symptoms,  and  bone  thickening,  first  demonstrable  by  the 
x-rays,  later  distinctly  palpable,  and  at  times  involving  the  entire  bone 
shaft.  Sequestration  and  sinus  formation  are  usual  but  not  invariable 
sequelae. 

The  early  distinction  from  malignant  growth  is  not  possible  except 
by  the  a;-rays,  and,  when  the  inflammatory  process  is  localized,  must 
often  be  made  by  operation. 

Tumors  of  the  Thigh. — ^Benign  tumors  of  the  bone  appear  in  the 
form  of  exostoses  and  chondromata,  growing  from  the  epiphyseal  line 


618 


THE  LOWER  EXTREMITY 


of  young  people.  Such  exostoses  are  subject  to  malignant  degeneration, 
hence  when  they  grow  rapidly  the  diagnosis  of  their  benignancy  should 
be  based  upon  removal  and  examination. 

Lipoma. — Lipoma  is  occasionally  observed  in  the  superficial  fascia 
and  corresponds  to  type,  forming  a  lobulated,  rather  sharply  circum- 
scribed mass,  with  dimpling  of  the  skin  on  pinching  it  up.  It  may 
form  a  diffuse  tumor  either  in  the  superficial  or  deep  fascia  and  is  not 
infrequently  associated  with  an  angioma,  in  which  case  the  diagnosis 
may  be  suggested  by  the  soft  consistency,  slow  growth,  usually  con- 
genital origin,  and  marked  change  in  size  incident  to  elevation  and 
depression. 

In  the  case  of  deep  vascular  growths  there  is  often  an  angiomatous 
condition  of  the  overlying  skin.     Exceptionally  lipoma  beneath  the  deep 


Fig.  419 


Fibrolipoma  of  the  thigh.  Twelve  years'  duration.  Overlying  skin  unaltered  and  non-adherent. 
Tumor  firm  in  consistency,  situated  beneath  deep  fascia,  and  movable  in  surrounding  tissues. 
(Carnett.) 


fascia  may  be  circumscribed,  forming  a  distinctly  hard  tumor.  The 
distinction  from  sarcoma  can  be  formulated  only  on  the  much  slower 
growth  of  the  fatty  tumor  and  by  operation. 

Carcinoma. — Carcinoma,  excepting  that  involving  the  skin,  occurs  in  the 
metastatic  form  and  may  be  the  underlying  lesion  of  a  spontaneous 
fracture. 

Sarcoma. — Sarcoma  originating  in  the  periosteum  or  soft  parts  has 
for  its  seat  of  predilection  the  adductor  portion  of  the  thigh.  It  is 
characterized  by  rapidity  of  growth.  Any  recent,  apparently  causeless 
tumor  in  this  region  should  suggest  the  probability  of  sarcoma. 

The  thigh  is  particularly  the  region  of  both  bone  sarcoma  and 
that  originating  in  the  connective  tissue  of  the  soft  parts.     The  bone 


THE  HIP 


619 


sarcoma  is  characterized  by  fixed,  harassing  pain,  later  by  spontaneous 
fracture  or  swelhng.  Early  diagnosis  is  possible  only  by  the  x-rays  or 
operation. 


Fig.  420 


Epithelioma  in  cicatrix  following  burn.      (Hartzell.) 

Bone  cyst,  being  of  slow  growth,  gives  few  symptoms.  Tumor  may 
be  first  noticed;  often  fracture  from  inadequate  force  is  the  earliest 
indication  of  a  lesion.     The  diagnosis  is  made  by  the  x-rays. 


THE  HIP. 


The  coarse  skin  of  the  buttock,  particularly  subject  to  boils,  covers, 
in  addition  to  the  gluteal  muscles,  much  fat  and  loose  connective  tissue. 
Lipomata  and  extensive  blood  effusions,  from  moderate  trauma,  are 
common  in  this  region. 

About  the  hip-joint  are  placed  a  number  of  bursas,  the  more  impor- 
tant of  which,  surgically,  are  the  trochanteric,  the  lliopectineal,  and  the 
ischial.     The  trochanteric  bursa  lies  between  the  deep  surface  of  the 


620  THE  LOWER  EXTREMITY 

gluteus  maximus  and  the  lateral  trochanteric  surface;  there  are  other 
smaller  bursal  sacs  lower  down  between  the  muscle  and  the  femoral 
shaft. 

The  large  iliopectineal,  called  also  the  iliopsoas  bursa,  lies  in  front 
of  the  capsule  of  the  hip-joint  between  this  structure  and  the  iliopsoas 
tendon;  a  second  smaller  bursa  lies  below,  nearer  the  femoral  attach- 
ment of  the  muscle. 

The  ischial  bursa  lies  over  the  prominence  of  the  ischium,  between 
this  structure  and  the  gluteus  maximus. 

The  lymphatics  of  the  buttock  empty  into  the  inguinal  and  the  deep 
pelvic  glands. 

In  the  groin,  which  is  limited  above  by  Poupart's  ligament  and  exter- 
nally by  a  line  drawn  from  the  anterior  superior  spine  to  the  top  of  the 
trochanter,  lie  two  sets  of  lymphatic  glands.  The  superficial  set,  in  the 
superficial  fascia,  containing  many  single  elements,  parallels  both 
Poupart's  ligament  and  the  long  saphenous  vein.  The  deep  set,  con- 
sisting of  a  few  glands,  lies  to  the  inner  side  of  the  femoral  vein.  Into 
these  glands  drains  the  lymph  of  the  lower  extremity,  the  buttock,  the 
anus,  the  perineum,  the  external  genitals,  and  the  lower  part  of  the 
abdominal  parietes. 

The  strong  ball-and-socket  hip-joint  moves  in  all  directions  with  a 
range  subject  to  marked  individual  variation.  Usually  the  thigh  can 
be  flexed  until  its  extensor  surface  is  in  contact  with  the  belly  wall.  With 
the  patient  in  ventral  decubitus  and  the  pelvis  held  firmly,  but  slight 
extension  is  possible.  Abduction,  adduction,  and  the  rotation  are  free 
within  their  limits. 

In  the  examination  of  the  hip-joint,  the  bony  landmarks  of  impor- 
tance are  the  anterior  superior  spine  of  the  ilium,  reached  by  fol- 
lowing the  crest  of  the  ilium  forward,  the  tuberosity  of  the  ischium, 
the  bony  projection  on  which  the  weight  is  borne  while  sitting,  and  the 
trochanter  major,  indicated  by  a  depression  in  fat  subjects,  made  more 
prominent  by  adduction  and  internal  rotation,  with  its  upper  border 
obscured  by  the  middle  gluteal  muscle.  The  posterior  superior  iliac 
spine  representing  the  posterior  extremity  of  the  iliac  crest,  and  often 
indicated  by  a  dimple,  marks  about  the  centre  of  the  sacro-iliac 
joint. 

The  gluteal  fold,  representing  the  crease  of  demarcation  between  the 
thigh  and  buttock,  lies  above  the  lower  border  of  the  gluteus  maximus. 
With  the  patient  standing  upright,  heels  together,  it  should  be  symmetri- 
cal on  the  two  sides.  It  is  obscured  or  obliterated  by  flexion  and  by 
deep  or  superficial  swellings. 

A  line  drawn  from  the  anterior  superior  iliac  spine  to  the  ischial 
tuberosity,  the  thigh  being  slightly  flexed,  crosses  the  palpable  top  of 
the  trochanter  (Nelaton's  line).  From  this  standard  of  conformation 
many  normal  individuals  depart.  The  line  is  serviceable  mainly  in 
comparing  the  trochanteric  position  on  the  two  sides  of  the  body  and 
then  only  when  the  person  examined  is  neither  overfat  nor  heavily 
muscled;  and  when  he  can  be  partially  turned  on  his  side  and  the 


THE  HIP  621 

trochanter  is   not  obscured   by  blood  effusion  or   inflammatory  swell- 

Bryant's  triangle  is  made  by  dropping  a  line  vertically  from  the  anterior 
superior  iliac  spine  to  the  flat  surface  on  which  the  patient  is  lying 
supine,  running  a  second  line  from  the  anterior  superior  spine  to  the 
top  of  the  trochanter,  and  a  third  from  this  point  perpendicular  to 
the  vertical  line  first  drawn.  This  last  line,  called  Bryant's  line,  is 
shortened  as  compared  to  that  of  the  sound  side  if  the  trochanter  be 
carried  upward  as  from  dislocation,  fracture,  or  deformity  of  the 
femoral  neck. 

The  normal  angle  made  by  the  junction  of  the  axis  of  the  shaft  of  the 
femur  with  that  of  its  neck  is  in  the  adult  about  130  degrees.  Behind 
the  femoral  artery,  just  below  the  point  where  it  crosses  the  pelvic  brim, 
lies  the  head  of  the  femur. 

The  symptoms  of  affection  of  the  hip-joint  are  pain,  tenderness, 
swelling,  muscular  contraction  and  atrophy,  limitation  or  exaggeration 
of  motion,  deformity,  and  the  local  and  constitutional  manifestations  of 
infection. 

The  pain  of  hip-joint  affection  is  aggravated  by  motion  or  jarring  of 
the  joint.  In  the  early  stages  of  inflammation  it  may  be  referred  to 
the  knee. 

Pain  may  be  referred  to  the  hip  as  a  result  of  lesion  elsewhere; 
appendicitis,  seminal  vesiculitis,  affections  of  the  prostate,  ovaries, 
tubes,  or  uterus  commonly  exhibit  this  reference.  Referred  pain  is 
uninfluenced  by  movements  or  jarring  of  the  joint,  though  it  excep- 
tionally occasions  a  limp.  The  symptoms  of  the  causative  lesion  are 
usually  pronounced. 

Swelling  incident  to  moderate  joint  effusion  is  not  appreciable  to 
touch.  The  swelling  usually  felt  is  periarticular,  representing,  in  case 
of  joint  involvement,  bony  thickening,  infiltration  of  soft  parts,  bursal 
involvement,  or  abscess  formation.  The  fluctuating  swellings  of  chronic 
bursitis  are  characterized  by  their  position. 

Muscular  contraction,  usually  first  expressed  in  the  iliopsoas,  limit- 
ing extension,  is  an  early  symptom  of  joint  inflammation.  The  atrophy 
is  earliest  demonstrable  in  the  gluteal  region  unless  there  be  inflamma- 
tory swelling  here,  though  all  the  thigh  muscles  participate. 

Malformations  of  the  Hip-joint. — Congenital  Dislocation,  exhibiting 
a  predilection  for  girl  babies,  usually  unilateral  and  due  to  develop- 
mental defect,  exceptionally  traumatic,  is  often  not  detected  in  fat 
children  until  they  begin  to  walk;  this  is  especially  the  case  when  the 
deformity  is  bilateral. 

When  the  affection  is  unilateral,  shortening  of  the  leg,  elevation  and 
undue  prominence  of  the  trochanter,  and  flattening  of  the  buttock  are 
suggestive  symptoms,  the  diagnostic  one  being  the  palpation  of  the 
abnormally  mobile  head  in  its  wrong  position,  facilitated  by  adducting 
and  rotating  the  thigh  and  pulling  and  pushing  upon  it.  The  ability 
to  cause  the  trochanter  to  move  up  and  down  by  alternately  pushing 
and  pulling  the  leg  is  highly  characteristic. 


622  THE  LOWER  EXTREMITY 

Bilateral  luxation  is  characterized  by  the  symptoms  of  the  unilateral 
affection,  except  that,  since  both  legs  are  shortened,  there  is  no  standard 
for  comparing  measurements. 

When  the  walking  age  is  reached  the  limp  in  the  unilateral  involve- 
ment, with  compensatory  lordosis  and  scoliosis,  the  waddling  gait 
in  bilateral  involvement,  with  compensatory  lordosis  and  prominent 
buttocks  and  belly,  associated  with  the  symptoms  already  given,  is 
characteristic.  The  a;-rays  give  the  easiest  and  surest  means  of  making 
a  diagnosis. 

Coxa  Vara. — Coxa  vara  is  a  deformity  of  late  childhood  and  puberty, 
commonest  in  boys,  characterized  usually  by  downward  and  backward 
bending  of  the  neck  of  the  femur  and  consequent  lessening  of  the  angle 
formed  by  its  long  axis  with  that  of  the  shaft.  It  is  an  affection  of 
gradual  development,  sometimes  secondary  to  fracture  of  the  neck, 
epiphyseal  separation,  rickets,  or  tuberculosis.  It  is  usually  independent 
of  such  causes. 

Coxa  vara  is  characterized  by  limp,  weakness,  and  pain  in  the  hip 
region  moderate  in  degree  and  aggravated  by  use,  outward  rotation  of 
the  thigh,  and  prominence  and  upward  displacement  of  the  trochanter. 

Examination  shows  limitation  of  abduction  and  also  to  some  extent 
of  inward  rotation  and  flexion.  Actual  shortening  of  the  limb  is  readily 
demonstrated;  this  is  rendered  apparently  greater  by  the  tilting  of  the 
pelvis  toward  the  sound  side  to  compensate  for  the  limited  abduction. 

The  distinction  from  tuberculous  coxitis  is  based  upon  the  obvious 
deformity  which  precedes  crippling  disability,  and  by  the  freedom  of 
extension  which  is  characteristic  of  coxa  vara.  In  tuberculous  coxitis 
limitation  of  extension  is  one  of  the  earliest  and  most  characteristic 
signs. 

In  congenital  luxation  of  the  hip-joint  the  head  of  the  bone  may  be 
felt  in  its  abnormal  position.  Shortening  can  be  lessened  by  traction 
and  can  be  increased  by  pushing  the  femur  upward.  The  exact  seat 
of  deformity  can  be  determined  only  by  the  x-rays. 

Coxa  Valga. — Coxa  valga,  a  condition  in  which  the  angle  made  by 
the  neck  of  the  femur  with  its  shaft  is  increased,  occurs  in  flabby 
adolescents,  causing  pain  in  the  hip,  lameness,  and  stiffness  of  the 
joint,  often  intermittent  at  first,  and  usually  an  outward  rotation  of  the 
femur,  with  abduction,  limitation  of  flexion,  and  stiffness  of  the  joint 
due  to  spasmodic  contraction  of  the  muscle.  There  is  necessarily  an 
increase  in  the  length  of  the  limb.  Diagnosis  is  based  upon  a;-ray  find- 
ings. There  is  associated  anterior  bowing  of  the  neck  of  the  femur, 
the  trochanter  minor  pointing  directly  inward  instead  of  backward  and 
inward. 

Contracture  and  ankylosis  of  the  hip-joint,  are  usually  caused  by  a 
preceding  joint  inflammation. 

A  flexion  contracture  incident  to  psoas  involvement  secondary  to 
spinal  caries  is  distinguished  by  the  absence  of  tenderness  in  the  hip- 
joint,  its  free  motions  within  the  limits  imposed  by  the  involved  muscle, 
and  the  symptoms  of  Pott's  disease. 


THE  HIP  623 

Rheumatic  contraction  affecting  children  and  marked  by  rapid 
onset  and  severe  pain  on  motion,  the  joint  being  fixed  in  moderate 
flexion  with  either  adduction  or  abduction,  can  be  distinguished  from 
beginning  tuberculous  coxitis  only  by  the  prompt  curative  effect  of 
appropriate  treatment.  In  its  mild  form  it  is  characterized  by  recurring 
transitory  limp.     Pain  is  the  dominant  symptom. 

Habit  contracture  incident  to  long  maintenance  of  flexed  position 
is  less  common  in  the  hip  than  in  the  knee-joint. 

The  contracture,  partial  fixation,  and  deformity  incident  to  senile 
arthritis  deformans,  have  the  associated  joint  symptoms  and  the  a?-ray 
picture  of  the  affection. 

The  gross  deformity  of  tabetic  arthropathy  is  painless  and  is  accom- 
panied by  other  characteristic  symptoms  of  the  disease. 

Paralytic  contractures  usually  associated  with  dislocation  backward 
if  the  abductors  and  external  rotators  are  involved,  forward  if  the 
paralysis  has  crippled  the  adductors,  is  characterized  by  muscular 
atrophy  and  elastic  fixation  in  either  flexion,  adduction  and  internal 
rotation,  or  abduction  and  outward  rotation,  and  the  finding  of  the  head 
of  the  bone  in  its  abnormal  position. 

Ankylosis  incident  to  a  previous  inflammation  is  compensated  for 
by  increased  mobility  of  the  spine  and  the  sacro-iliac  articulation.  It 
is  a  common  sequel  of  gonococcal  and  rheumatic  inflammation. 

Tuberculous  inflammation  is  more  prone  to  result  in  extensive  destruc- 
tion of  the  head  and  neck  of  the  bone  and  upward  displacement  of  the 
trochanter.  Coxitis  of  typhoid  origin  is  frequently  complicated  by 
backward  luxation. 

The  determination  of  bony  flxation,  because  of  the  mobility  of  the 
pelvis,  is  difficult,  and  is  best  determined  by  the  a;-rays. 

Trauma  of  the  Hip. — Contusion  of  the  Soft  Parts. — Contusion  of  the 
soft  parts  exhibits  extensive  blood  effusion  which  is  slowly  absorbed. 
Either  the  iliopsoas  or  the  ischiatic  bursa  may,  as  a  result  of  blood 
effusion,  form  a  prominent,  fluctuating  or  semisolid,  crepitating,  circum- 
scribed tumor  lying  in  the  bursal  region  and  persisting  after  the  sub- 
cutaneous blood  effusion  has  been  absorbed.  The  diagnosis  is  based 
upon  the  history  of  trauma  and  the  seat  of  tumor.  Such  traumatized 
bursse  may  subsequently  become  the  seat  of  hygromata. 

Contusion  of  the  Hip-joint. — Contusion  of  the  hip-joint  is  evidenced 
by  local  pain,  and  the  signs  of  bruising,  often  associated  with  the  com- 
plete disability,  extreme  tenderness,  and  outward  rotation  which  are  char- 
acteristic of  fracture.  Since  the  latter,  if  intracapsular,  may  be  attended 
with  none  of  the  well-marked  signs  of  this  condition,  the  differential 
diagnosis  may  be  impossible  without  the  help  of  the  x-rays. 

An  injury  to  the  hip  sufficiently  severe  to  cause  complete  disability 
is  usually  a  fracture,  the  patient  rarely  having  the  power,  when  the  leg 
is  broken  and  non-impacted,  of  flexing  the  thigh  even  to  a  slight  degree 
on  the  pelvis. 

Contusions  of  the  joint  attended  with  much  less  marked  symptoms 
may  in   young   people   produce   epiphyseal   separation   or  incomplete 


624  THE  LOWER  EXTREMITY 

fracture  of  the  neck  suggested  by  slow  and  incomplete  convalescence 
and  ultimate  deformity.  The  a;-rays  afford  the  only  means  of  making 
an  early  diagnosis. 

Fractures  in  and  about  the  Hip-joint. — The  fracture  may  involve  the 
trochanters,  the  neck  of  the  femur  or  its  head,  or  the  acetabulum. 
Usually  they  are  of  the  femoral  neck. 

Fractures  of  the  Neck  of  the  Femur. — The  injury  may  be  an 
epiphyseal  separation  of  the  head,  a  fracture  of  the  junction  of  the 
head  and  neck,  which  may  be  incomplete  or  impacted,  a  fracture  of 
any  portion  of  the  neck,  or  a  fracture  of  the  junction  of  the  neck  and 
trochanter,  often  impacted  and  both  intracapsular  and  extracapsular. 

In  children  traumatic  separation  of  the  head  of  the  femur  at  the 
epiphyseal  line  or  fracture  of  the  neck  of  the  bone  may  be  partial 
or  complete.  The  complete  fracture  is  usually  impacted  with  down- 
ward bending  of  the  neck.  It  is  due  to  a  heavy  fall  upon  the  hip, 
resulting  in  local  pain  and  swelling,  and  disability  characteristic  in  its 
extent  of  that  of  bruise  rather  than  of  fracture.  Recovery  is,  however, 
neither  rapid  nor  complete.  There  is  continual  lameness  and  dis- 
comfort. 

The  diagnosis  is  based  upon  a  careful  examination  which  shows  eleva- 
tion of  the  trochanter  of  the  affected  side  (one-half  to  one  inch),  and 
usually  limited  abduction,  flexion,  and  inward  rotation.  The  positive 
diagnosis  of  these  injuries  should  be  made  by  the  x-rays. 

In  the  adult  the  seats  of  fracture  are  at  the  junction  of  the  head  and 
neck  and  the  junction  of  the  neck  ^and  shaft.  In  the  former  position 
the  break  is  always  intracapsular  and  is  exceptionally  impacted.  It 
results  from  application  of  force  in  the  long  axis  of  the  femur,  as  from 
unexpectedly  slipping  down  a  stair,  or  falling  upon  the  knee,  or  from 
trifling  violence. 

Fracture  at  the  junction  of  the  neck  and  shaft  is  usually  comminuted 
and  intracapsular  in  front  and  extracapsular  behind,  or  entirely  extra- 
capsular, and  is  frequently  impacted,  this  impaction  being  more  marked 
posteriorly.  It  results  from  a  fall  upon  the  hip,  which,  except  in  the 
aged  or  those  subject  to  fracture,  must  be  heavy. 

Fractures  of  the  neck  of  the  femur  are  characterized  by  disability 
which  may  be  only  partial  in  impacted  fractures;  by  shortening,  as 
shown  by  measurement  from  the  anterior  superior  spinous  process 
of  the  ilium  to  the  internal  malleolus,  the  interspinous  line  being  at 
right  angles  to  the  long  axis  of  the  body  and  the  legs  of  the  two  sides 
being  held  in  similar  position  both  in  their  relation  to  this  line  and  in 
regard  to  their  degree  of  flexion  and  rotation;  by  elevation  of  the  tro- 
chanter to  the  extent  of  the  shortening  as  determined  by  Bryant's  line; 
by  lack  of  parallelism  between  two  lines,  one  of  which  connects  the  two 
anterior  superior  iliac  spines,  the  other  the  tips  of  the  trochanters;  by 
outward  rotation,  the  back  of  the  heel  of  the  injured  side  lying  in  con- 
tact with  the  tendo  Achillis  on  the  sound  side  when  the  legs  are  brought 
together;  by  lessened  resistance  in  the  space  between  the  top  of  the  tro- 
chanter and  the  crest  of  the  ilium;  by  crepitus,  in  free  fractures,  elicited  by 


THE  HIP 


625 


pressure  upon  the  trochanter,  supplemented  by  traction  and  movements 
of  the  joint;  by  rotation  of  the  trochanter  about  the  arc  of  a  circle  with 
a  less  diameter  than  that  of  the  sound  side.  There  is,  moreover,  swell- 
ing, most  rapid  and  pronounced  when  the  fracture  is  extracapsular, 
pain  greatly  aggravated  by  motion,  and  tenderness  on  palpation  most 
marked  at  the  seat  of  injury. 

When  the  shortening  and  external  rotation  are  slight,  the  disability 
not  complete,  the  swelling  pronounced  and  rapid,  the  pain  severe,  the 
trochanter  obviously  widened  to  the  examining  hand,  blood  effusion  and 
skin  discoloration  prompt  and  widespread,  and  the  injury  is  due  to 
direct  violence  to  the  trochanter,  it  is  probable  the  fracture  is  extra- 
capsular and  impacted.  Under  such  circumstances,  unless  there  be 
great  deformity,  no  effort  should  be  made  to  elicit  crepitus  or  undue 
mobility. 

When  the  injury  is  trifling  and  not  directly  applied  to  the  trochanter, 
even  though  there  be  but  slight  shortening  of  Bryant's  line,  if  absolute 

Fig.  4211 


Fracture  through  small  part  of  neck  of  femur,  in  female,  aged  fifty-four  years.     Ununited  (with 
shortening)  eight  weeks  after  injury.     Injury  neither  diagnosticated  nor  treated  as. a  fracture.. 


1  Fig.  421.     Outline  drawing  from  radiograph  by  Dr.  H.  K.  Pancoast  in  collection  of  Univer- 
sity Hospital  x-ray  Laboratory.     (Referred  by  Dr.  Willard.) 

40 


626  THE  LOWER  EXTREMITY 

disability  is  associated  with  pronounced  outward  rotation,  it  is  probable 
the  fracture  is  intracapsular  and  non-impacted. 

Contusion  of  the  thigh  does  not  cause  shortening,  but,  since  in  frac- 
ture the  latter  may  be  so  slight  as  to  be  difficult  of  demonstration,  the 
differential  diagnosis  must  be  made  by  the  x-rays. 

Fracture  of  the  great  trochanter  due  to  direct  violence,  rare  except 
as  a  complication  of  fracture  of  the  neck,  then  usually  comminuted, 
can  be  detected  in  the  absence  of  mobility  or  displacement  only  by  the 
x-rays,  or  by  severe  and  persistent  bone  pain  and  tenderness  and  the 
elimination  of  other  lesions. 

The  distinction  between  fracture,  the  common  injury,  and  luxation, 
which  is  comparatively  rare,  is  based  upon  the  characteristic  and  elas- 
tically  fixed  position  of  the  thigh  and  leg  in  backward  luxation  and  the 
obvious  displacement  of  the  head  of  the  bone  and  the  trochanter  in 
those  rare  dislocations  characterized  by  outward  rotation  and  abduction. 

Fracture  of  the  acetabulum,  usually  a  chipping  off  of  a  portion  of  its 
brim  and  constituting  a  complication  of  luxation,  may  be  suggested  by 
deep  crepitus  on  manipulation,  easy  reduction  of  a  partial  luxation 
and  a  tendency  toward  recurrence  of  deformity  on  removal  of  extending 
force.  An  assured  diagnosis  of  this  condition  is  rarely  possible  without 
the  use  of  the  x-rays. 

Extensive  fracture  of  the  acetabulum  may  be  suggested  by  shortening 
of  the  leg  of  the  affected  side,  absence  of  the  normal  prominence  of 
the  trochanter,  and  by  comparatively  easy  reduction  of  the  deformity 
by  extension  with  its  recurrence  on  removal  of  the  extending  force. 
Rectal  examination  has  sometimes  revealed  crepitus  and  blood  effusion. 
Diagnosis  should  be  made  by  the  x-rays. 

Luxation  of  the  Hip-joint. — Traumatic  dislocation  of  the  hip-joint, 
commonest  in  vigorous  adult  males,  is  characterized  by  an  elastic  fixa- 
tion of  the  thigh,  which  varies  in  accordance  with  whether  the  head  of 
the,  bone  lies  without  (behind)  or  within  (in  front  of)  a  line  passing 
from  the  anterior  superior  spinous  process  of  the  ilium  to  the  ischial 
tuberosity. 

Outward  or  posterior  luxation  (iliac  or  ischiatic)  is  characterized  by 
flexion,  adduction  and  inward  rotation  incident  to  the  pull  of  an  intact 
Y-ligament,  and  shortening.  If  the  Y-ligament  be  ruptured,  the  position 
will  depart  from  type.  The  head  of  the  displaced  bone  can  often  be 
felt  beneath  the  gluteus  muscles,  and  its  absence  from  the  normal  position 
will  be  shown  by  loss  of  deep  resistance  on  pressure  upon  the  femoral 
artery  just  below  the  pubic  bone.  The  trochanter  is  displaced  upward. 
Involvement  of  the  sciatic  nerve  will  be  indicated  by  severe  pain  radiat- 
ing along  the  course  of  this  trunk. 

Complicating  acetabular  fracture  may  be  suggested  by  crepitus  on 
manipulation  and  ease  in  reduction.  The  diagnosis  of  the  presence  or 
absence  of  associated  bone  lesions  should  be  made  by  the  x-rays. 

The  determination  as  to  whether  the  luxation  is  iliac  or  ischiatic  is 
dependent  rather  upon  palpating  the  head  of  the  bone  in  its  abnormal 
position  than  upon  the  greater  degree  of  adduction  and   inversion  as 


THE  HIP 


627 


compared  to  flexion  and  shortening,  since  the  individual  case  gives 
no  standard  for  such  comparison. 

Internal  (anterior)  luxation,  thyroid  or  pubic,  in  accordance  with  the 
position  of  the  head  of  the  bone,  is  characterized  by  abduction  and 
outward  rotation  of  the  flexed  thigh.  Shortening  is  trifling  or  absent 
in  the  obturator  form.  The  head  of  the  femur  is  felt  in  its  abnormal 
position,  the  trochanteric  prominence  is  lessened. 


Fig.  422 


Fig.  423 


Dislocation  of  hip.     (Park.) 


The  pubic  luxation  is  characterized  by  marked  shortening,  obvious 
groin  tumor  formed  by  the  femoral  head,  usually  slight  or  absent  flexion. 
If  the  head  of  the  femur  be  pushed  beneath  Poupart's  ligament,  there 
may  be  inward  rotation. 

Pathological  dislocation  incident  to  previous  disease  of  the  bone  or 
joint  is  characterized  by  marked  shortening  of  sudden  development,  with- 
out obvious  traumatic  cause,  occurring  in  the  course  of  a  hip  affection. 
This  in  itself  is  diagnostic,  fracture  being  excluded  by  the  x-rajs.  Such 
a  luxation  may  occur  in  consequence  of  a  typhoid  arthritis  unnoticed  at 
the  time  of  its  occurrence,  because  of  the  adynamic  condition  of  the 
patient,  and  not  detected  until  convalescence. 


628  THE  LOWER  EXTREMITY 

Affections  of  the  Bursse  about  the  Hip-joint. — Inflammation  of 
the  deep  trochanteric  bursa,  if  acute,  is  commonly  traumatic  or  sec- 
ondary to  direct  or  systemic  infection;  if  chronic,  is  usually  tuberculous. 
It  is  characterized  by  a  tender,  fluctuating  swelling,  at  times  bilocular, 
placed  above  and  behind  the  trochanter  and  exhibiting  fairly  sharp 
outlines.  The  thigh  is  held  in  abduction,  outward  rotation,  and  slight 
flexion.  The  motions  of  the  hip-joint  which  do  not  increase  the  ten- 
sion of  the  bursa  are  free  and  painless. 

Diagnosis  is  based  upon  the  position  of  the  tumor,  its  fluctuating  char- 
acter, and  its  indolence;  should  it  present  the  consistency  of  solid  growth, 
by  excision  and  examination,  since  sarcoma  may  be  primary  in  the  bursa. 

Iliopsoas  bursitis  forms  a  fluctuating,  tender  tumor,  often  bilocular, 
and  occasioning  severe  pain  along  the  course  of  the  anterior  crural 
nerve.  It  may  reach  the  size  of  a  child's  head,  filling  the  upper  part  of 
Scarpa's  triangle  and  making  prominent  the  femoral  artery.  Extension 
of  the  thigh  on  the  pelvis  is  painful,  flexion,  abduction,  and  outward 
rotation  being  the  usual  position. 

The  diagnosis  is  based  upon  the  position  of  the  tumor,  the  greater 
prominence  and  tension  on  extension  of  the  thigh  on  the  pelvis,  and,  if 
the  walls  be  so  thick  as  to  obscure  fluctuation  and  simulate  solid  growth, 
by  excision  and  examination. 

Ischiatic  bursitis  is  characterized  by  a  fluctuating  swelling  over  the 
ischiatic  tuberosity.  It  may  become  acutely  inflamed,  forming  a  deep 
phlegmon.     The  diagnosis  is  based  upon  its  position. 

Arthritis  of  the  Hip. — Traumatic  Arthritis. — ^Traumatic  arthritis  inci- 
dent to  contusion  or  sprain  is  attended  by  characteristic  tenderness  to 
deep  pressure,  pain,  limitation  of  movement,'  and,  in  its  severe  form, 
muscular  atrophy.  If  recovery  be  not  complete  and  fairly  prompt,  asso- 
ciated bone  lesion  should  be  suspected.  Trauma  in  middle-aged  and 
elderly  men  is  often  the  apparent  cause  of  arthritis  deformans. 

Acute  Infectious  Arthritis. — Acute  infectious  arthritis  of  the  hip,  a 
localization  of  systemic  infection,  usually  rheumatic  or  gonorrheal,  at 
times  typhoidal,  influenzal,  pneumonic,  diphtheritic,  scarlatinal,  or  inci- 
dent to  a  number  of  other  less  common  infections,  is  characterized  by 
pain,  aggravated  by  motion,  tenderness,  fixation,  swelling  which,  because 
of  the  deep  position  of  the  joint,  is  not  immediately  demonstrable,  and, 
if  the  infection  is  actively  proliferating  and  producing  extensive  destruc- 
tion of  tissue  as  typified  by  the  staphylococcus  and  streptococcus,  the 
symptoms  of  profound  sepsis. 

Gonococcal  arthritis  is  characterized  by  extreme  pain.  In  the  hip-joint 
it  is  usually  of  the  plastic  type  resulting  in  ankylosis.  Children  are  not 
immune  against  this  form  of  coxitis. 

Rheumatic  arthritis,  usually  polyarticular  and  migratory,  if  monartic- 
ular, is  diagnosticated  as  such  on  the  basis  of  constitutional  symptoms 
and  on  the  absence  of  other  recognized  infecting  causes. 

Typhoidal  arthritis  is  characterized  by  large  joint  effusion,  with  other 
symptoms  but  slightly  marked.  Occurring  as  it  does  at  the  period  of 
maximum  illness,  it  is  often  overlooked  until  luxation  calls  attention  to  it. 


THE  HIP  629 

Osteomyelitic  arthritis  is  commonly  observed  in  infants  and  children. 
There  is  profound  sepsis.  Joint  tenderness  and  fixation  are  char- 
acteristic, edematous  periarticular  swelling  develops  rapidly,  followed 
shortly  by  softening  and  fluctuation.  There  is  often  epiphyseal  separa- 
tion, or  necrosis  of  the  head  and  the  neck  of  the  bone.  The  joint  is  not 
always  involved  in  trochanteric  osteomyelitis. 

Pneumococcal  arthritis  also  occurs  at  or  shortly  after  the  period  of 
maximum  illness.  The  effusion  is  commonly  suppurative  and  the 
symptoms  acute. 

Traumatic  arthritis  or  any  of  the  acute  infections  may  become  chronic. 
Other  forms  of  arthritis  begin  insidiously  and  are  chronic  from  the  start. 
Tuberculous  arthritis  is  the  most  conspicuous  example  of  this  class. 

Tuberculosis  of  the  Hip-joint. — Tuberculosis  of  the  hip-joint,  com- 
monest in  children  after  the  second  and  before  the  tenth  year,  rare  in 
infants  and  adults;  usually  begins  in  or  near  the  epiphyseal  line  of  the 
femoral  head;  it  may  be  synovial  or  acetabular  in  onset. 

Tuberculous  heredity  or  disease  in  other  parts  of  the  body  is  a  pre- 
disposing factor.  It  may  develop  in  children  who  apparently  are  per- 
fectly well.  The  first  symptom  is  usually  an  intermitting  limp,  usually 
attributed  to  slight  trauma.  Pain,  which  is  also  intermittent,  is  often 
referred  to  the  knee,  and  as  the  disease  progresses  it  is  marked  by  recur- 
ring brief  nocturnal  paroxysms  causing  the  t}^ical  night  cries. 

Examination  in  the  early  stage  shows  limitation  in  the  joint  move- 
ments due  to  muscular  spasm,  tenderness,  muscular  atrophy,  and  possi- 
bly trochanteric  thickening. 

Limitation  of  movement  is  the  most  important  single  diagnostic  sign 
of  arthritis.  Slight  motions  may  be  free  and  unimpeded,  but  the  full 
movement  of  the  joint  is  always  arrested,  and  usually  in  all  directions, 
though  the  limitation  is  most  pronounced  in  the  direction  of  extension. 

Atrophy  is  evidenced  in  both  the  thigh  and  gluteal  muscles;  at  times 
it  can  be  demonstrated  by  measurement  before  it  is  obvious  to  inspec- 
tion. Partly  because  of  this  atrophy,  but  mainly  on  account  of  the 
slight  flexion  in  which  the  joint  is  customarily  held,  the  gluteal  fold  is 
less  marked  than  on  the  sound  side. 

In  the  early  stages  the  thigh  is  slightly  flexed,  rotated  outward  and 
abducted,  and  while  walking  during  the  limp  periods  the  ankle  of  the 
affected  side  is  extended  and  the  knee  flexed  to  save  the  joint  from  jar. 

Direct  examination  in  the  early  stages  has  for  its  end  the  detection 
of  limited  motion,  of  tenderness,  of  muscular  atrophy,  and  trochanteric 
thickening.  The  garments  must  therefore  be  so  arranged  that  the  lower 
part  of  the  body,  the  pelvis,  and  the  lower  extremities  can  be  seen  and 
the  two  sides  compared.  With  the  patient  in  dorsal  decubitus,  the  legs 
are  brought  together,  as  nearly  as  possible  parallel  with  the  long  axis  of 
the  body;  if  one  thigh  be  fixed  in  abduction,  this  is  only  possible  by 
lateral  tilt  of  the  pelvis,  hence  a  line  drawn  from  one  anterior  iliac  spine 
to  the  other  will  not  make  a  right  angle  with  the  midline  of  the  trunk. 

The  limb  of  the  sound  side  is  grasped  by  the  ankle,  and  with  the  other 
hand  resting  upon  the  ilium  to  detect  any  movement  in  it,  the  knee  is 


630 


THE  LOWER  EXTREMITY 


flexed  upon  the  thigh,  and  the  thigh  upon  the  pelvis  to  tht  fullest  extent; 
thereafter  motions  of  abduction,  adduction,  and  rotation  are  practised. 
A  similar  examination  is  then  conducted  with  the  leg  and  thigh  of  the 
affected  side,  the  hand  on  the  ilium  noting  the  moment  when  this  bone 
participates  in  the  thigh  movements.  The  motion  is  usually  limited 
by  an  elastic  resistance  (muscular)  in  all  directions,  but  particularly 
in  extension  and  adduction  and  internal  rotation. 

Fig.  424 


Subacute  coxitis  Hip-joiat  held  in  position  of  flexion,  eversion,  and  abduction.  Eversion  is 
indicated  by  the  outward  rotation  of  the  foot  and  flexion  by  the  lordosis  in  the  lumbar  spine  during 
full  extension  of  the  thigh.     Compare  with  Fig.  425.     (Camett.) 


Fig.  425 

'"^^^. 

^^■^^^■4    V.     -ve^^^^^^^^ 

^^^^HHfe^^^l^^^^^^A 

^^^IW^^m 

Subacute  coxitis.  Same  patient  as  in  Fig.  424.  The  degree  of  flexion  deformity  at  the  hip- 
joint  from  spasm  of  the  ilippsoas  is  indicated  by  the  extent  to  which  the  thigh  must  be  flexed  to 
abolish  the  lumbar  lordosis.     (Camett.) 


To  detect  the  slight  flexion,  an  invariable  early  symptom  of  coxitis, 
with  the  patient  in  dorsal  decubitus,  the  sound  limb  is  flexed  until  the 
knee  touches  the  chest.  If  no  flexion  exists,  the  popliteal  space  upon 
the  affected  side  can  be  made  to  touch  the  table.  Both  thighs  are  flexed 
until  the  small  of  the  back  lies  flat  on  the  table.  The  thigh  and  knee  of 
the  sound  side  are  then  extended  until  the  popliteal  space  is  in  contact 
with  the  table  surface.  An  effort  to  place  the  affected  limb  in  the  same 
position  is  immediately  followed  by  arching  of  the  lumbar  spine. 


THE  HIP  631 

The  test  for  limited  extension  is  applied  by  placing  the  patient  in 
ventral  decubitus  and  lifting  the  straight  legs  from  the  table,  the  pelvis 
being  held  down.  In  a  healthy  child  the  hip-joint  can  be  hyperextended 
until  it  makes  an  angle  of  about  10  degrees  with  the  surface  on  which 
the  child  lies. 

The  circumference  of  both  thighs  is  measured  for  muscular  atrophy 
at  the  same  point,  usually  just  below  the  gluteal  fold,  the  limbs  being  held 
in  exactly  the  same  position  for  this  measurement. 

Tenderness  is  elicited  by  palpation  anteriorly  and  posteriorly,  by 
jarring  the  trochanter,  by  flexing  the  leg  at  the  knee  and  jarring  the  end 
of  the  femur  with  the  ball  of  the  hand.  This  sign  usually  has  been 
sufficiently  demonstrated  beforehand  in  the  examination  for  limitation 
of  motion. 

Trochanteric  thickening  is  detected  by  palpation  and  comparison 
with  the  trochanter  on  the  unaffected  side. 

These  symptoms,  if  present,  simply  prove  that  the  hip-joint  is 
inflamed. 

The  tuberculous  nature  of  this  inflammation  is  suggested  by  the  age 
of  the  patient,  the  absence  of  adecjuate  cause,  and  particularly  by  the 
slow  but  progressive  evolution.  The  tuberculin  test  is  corroborative 
and  the  a;-ray  findings  are  at  times,  in  themselves,  diagnostic,  both  as 
to  the  nature  of  the  affection  and  its  seat. 

Sprain  or  contusion  of  the  hip-joint,  or  sprain  or  rheumatic  myositis 
of  the  iliopsoas  muscle,  exhibit  similar  symptoms.  There  is  usually 
an  adequate  cause,  and  recovery  is  prompt  and  complete  under  appro- 
priate treatment. 

The  joint  irritation  incident  to  an  unrecognized  epiphyseal  separation 
or  partial  fracture  of  the  neck  of  the  bone,  in  the  absence  of  shortening 
sufficient  to  be  demonstrated  by  measurement,  can  be  distinguished  from 
tuberculous  arthritis  following  trauma  only  by  the  x-rays. 

In  lumbar  Pott's  disease,  among  other  symptoms,  there  will  be  pain, 
limp,  and  muscular  fixation  of  the  leg  in  much  the  position  characteristic 
of  coxalgia.  Fixation  is,  however,  only  against  extension,  other  move- 
ments being  free,  the  hip-joint  is  not  tender,  and  the  spinal  seat  of  the 
trouble  is  readily  determined  if  search  be  made  for  it.  The  two  con- 
ditions are  sometimes  associated. 

From  coxa  vara,  the  distinction  is  suggested  by  the  different  age  inci- 
dence, the  slower  progression  of  symptoms,  the  elevation  of  the  greater 
trochanter  in  the  absence  of  the  evidence  of  extensive  bone  or  joint 
involvement,  and  the  findings  of  the  a:-rays. 

Acute  epiphysitis  of  infancy  and  childhood  is  characterized  by  violent 
onset,  rapid  course,  and  early  and  free  pus  formation. 

In  sacro-iliac  disease  the  thigh  and  leg  are  carried  straight,  there  is 
tenderness  over  the  sacro-iliac  joint,  and  all  hip  motions  are  free,  except 
those  which  throw  a  strain  directly  upon  the  sacro-iliac  joint. 

Hysterical  joint  is  marked  by  an  incoordination  and  irregularity  of 
symptoms,  with  pain  dominant,  and  is  associated  with  other  signs  of 
hvsteria.     Moreover,  the  age  incidence  is  different. 


632  THE  LOWER  EXTREMITY 

In  cases  of  referred  pain  the  joint  movements  are  free. 

Chronic  arthritis,  secondary  to  subacute  or  chronic  osteomyeHtis 
in  its  development  and  progress,  closely  simulates  tuberculous  arthritis. 
Recovery  may  take  place  without  suppuration,  but  with  both  deformity 
and  disability.  Usually  abscesses  form,  discharging  for  months  or  years. 
Healing  is  followed  by  recurrence  of  inflammation.  The '  differential 
diagnosis  is  dependent  upon  bacterial  examination,  including  animal 
inoculation  and  the  tuberculin  test. 

Arthritis  Deformans. — Arthritis  deformans,  exceptionally  observed  in 
young  people  and  then  secondary  to  trauma,  usually  developing  spon- 
taneously in  persons  past  forty,  is  characterized  by  pain  usually  attrib- 
uted to  sciatica,  limp  most  marked  after  rest,  limitation  of  motion, 
muscular  atrophy,  joint  crepitus,  cartilaginous  erosion,  bony  outgrowth 
demonstrable  by  the  x-rays  long  before  they  can  be  palpated  externally, 
and  elevation  of  the  trochanter  of  the  affected  side.  Early  diagnosis 
is  suggested  by  limited  abduction  and  abnormal  elevation  of  the  tro- 
chanter, and  is  confirmed  by  the  ir-rays. 

Tabetic  Arthropathy. — Tabetic  arthropathy  of  the  hip-joint,  at  times 
an  early  symptom  of  tabes,  is  characterized  by  pronounced  swelling  of 
rapid  development  due  to  sudden  effusion  into  the  joint,  without  pain, 
markedly  increased  disability,  or  other  symptoms  of  inflammation.  Later 
there  is  destruction  of  joint  surfaces,  at  times  spontaneous  luxation. 

Syringomyelia  produces  similar  changes. 

Tumors  of  the  Hip. — These,  with  the  exception  of  the  superficial 
lipomata  and  the  exostoses  and  chondromata,  which  may  grow  from 
either  the  pelvic  bones  or  the  femur,  should  be  regarded  as  malignant 
unless  they  have  been  existent  and  stationary  for  such  a  long  period  as  to 
make  the  assumption  improbable. 

The  early  diagnosis  should  be  made  by  the  x-rays.  These  should 
be  employed  when  there  is  complaint  of  persistent,  deep-seated,  localized 
bone  pain  in  the  absence  of  joint  involvement.  In  case  of  doubt,  with 
the  seat  of  lesion  indicated  by  the  x-rays,  the  diagnosis  should  be  by 
operation. 

Huge  tumor,  rapid  growth,  dilated  superficial  veins,  and  eggshell 
crackling  are  symptoms  highly  characteristic,  but  too  late,  as  a  rule,  to 
be  of  service  to  the  patient. 

Thick-walled  bursse  and  subaponeurotic  lipomata  should  be  diagnos- 
ticated as  such  by  removal. 

Hysterical  Joint. — Hysterical  joint  may  closely  simulate  organic  dis- 
ease, since  pain,  tenderness,  swelling,  heat,  and  muscular  contraction 
may  all  be  present.  Pain  and  tenderness  are  out  of  proportion  to 
the  findings.  There  is  a  lack  of  consistency  in  the  symptoms,  and 
contractions  disappear  under  etherization.  Moreover,  there  is  a  history 
of  other  hysterical  seizures  and  other  unmistakable  symptoms  of  this 
condition.  The  contraction  usually  involves  the  adductors  and  internal 
rotators.     It  may  be  entirely  involuntary. 

Snapping  hip,  by  which  is  meant  the  power  of  partly  displacing  the 
hip  upon  the  upper  border  of  the  acetabulum,  may  become  habitual. 


THE  BUTTOCKS  633 


THE  BUTTOCKS. 

Either  wound  or  contusion  of  the  buttocks  may  be  followed  by  a  deep 
extravasation  of  blood  incident  to  partial  or  complete  rupture  of  the 
gluteal,  the  pudic,  or  the  sciatic  artery.  This  may  result  in  the  forma- 
tion of  a  progressive,  fluctuating,  painful  tumor  which,  even  though  it 
present  neither  thrill  nor  bruit,  is  necessarily  due  to  hemorrhage  because 
of  its  rapid  (hours)  development. 

When  the  blood  extravasation  is  more  gradual  and  more  efficiently 
limited  by  inflammatory  reaction  of  the  surrounding  soft  parts,  the 
resultant  traumatic  aneurysm  may  exhibit  the  tenderness,  pain,  and  rate 
of  growth  which  would  be  characteristic  of  a  deep  infected  thrombus. 
Pronounced  constitutional  symptoms  are  absent,  and  thrill  and  bruit 
have  usually  been  present,  together  with  severe  pain  incident  to  nerve 
pressure.  In  the  absence  of  characteristic  aneurysm  symptoms,  a  pre- 
vious history  of  trauma  should  suggest  the  possibility  of  aneurysm. 

The  distinction  from  cold  abscess  pointing  backward,  or  from  gluteal 
hernia,  may  be  impossible  without  direct  exploration.  Both  the  trau- 
matic and  idiopathic  gluteal  aneurysm  may  be  first  suggested  by  severe 
sciatic  pain  before  the  development  of  a  palpable  pulsating  tumor. 

Gluteal  Hernia.^ — Gluteal  hernia  (rare)  forms  a  tumor  which  may  be 
partly  or  wholly  reducible,  and  may  be  resonant.  It  is  rarely  detected 
until  it  projects  beneath  the  gluteus  maximus  into  the  perineum  or  until 
symptoms  of  strangulation  or  incarceration  are  accompanied  by  pain 
and  tenderness  in  the  region  of  the  sciatic  notch,  with  possibly  pressure 
pain  radiating  down  the  leg. 

Abscess. — Abscess  centring  in  the  gluteal  region  may  originate  from 
iliac  or  sacro-iliac  osteomyelitis  or  from  postperitoneal  or  purulent  collec- 
tions, or  those  of  spinal  origin.  The  diagnosis  is  usually  based  upon  the 
symptoms  of  the  original  infection.  In  the  absence  of  these  it  may  be 
difficult. 

Sarcoma. — Sarcoma  originating  in  the  soft  parts  of  the  buttocks  is 
rare.  Diagnosis  should  be  formulated  by  the  immediate  removal  of  a 
tumor  not  obviously  benign. 

Sacrococcygeal  Tumors  of  Congenital  Origin. — A  hernial  protrusion  of 
the  dura  may  occur  at  the  coccygeal  junction,  often  associated  with 
lymphangiomatous  or  teratomatous  growth.  The  latter  are  common 
in  this  region  as  are  also  dermoids  which  may  be  simple  or  compound 
implantation  cysts,  and  sarcomata. 

The  congenital  tumors  of  the  coccyx  grow  downward  rather  than 
upward,  lymphangioma  and  teratoma  complicating  meningocele  on  the 
dorsal  surface  of  the  coccyx;  whereas  teratomata,  congenital  lipomata, 
and  cystic  lymphangiomata  are  found  in  front  of  the  coccyx,  lying 
between  this  bone  and  the  rectum,  and  exhibiting  no  dural  connection 
(Steinthal). 

The  diagnosis  of  these  tumors  is  based  mainly  on  their  congenital  origin. 

The  dermoid  placed  over  the  coccyx  or  lower  portion  of  the  sacrum 


634 


THE  LOWER  EXTREMITY 


in  the  midline  is  fairly  common.  It  usually  excites  no  attention  until  it 
becomes  inflamed.  Suppuration  is  followed  by  a  persistent  midline 
sinus,  usually  mistaken  for  rectal  fistula.  Diagnosis  is  made  by  probe, 
often  by  the  finding  of  hair  in  the  discharge. 

Anterior  sacral  meningocele  (rare),  forming  a  tumor  detected  by  rectal 
palpation,  may  be  recognized  by  the  bony  defect  shown  by  the  x-rays,  and 
by  aspiration  and  examination  of  the  fluid. 

Dermoids  in  the  pelvic  connective  tissue  are  usually  not  recognized  as 
such  until  operation.     They  may  remain  latent  until  adult  life. 


Fig.  426 


Syphilodennic  tubercle.     Closely  resembling  lupus  vulgaris. 

Coccygodynia  is  a  term  applied  to  pain  greatly  aggravated  by  move- 
ments of  the  coccyx  such  as  are  incident  to  sitting  down,  defecating  or 
coughing,  and  reaching  its  maximum  intensity  incident  to  direct  palpa- 
tion. It  may  be  due  to  an  arthritis,  a  neuritis,  a  chronic  osteomyelitis, 
or  be  without  assignable  cause.  It  frequently  follows  traumatism.  It 
is  often  simulated  by  the  hysterical. 

The  pubic  joint  may  be  congenitally  absent,  the  pubic  bones  being 
widely  separated  from  each  other.  This  is  a  common  complication  of 
exstrophy  of  the  bladder.  The  motion  of  this  joint  is  a  vertical  sliding 
one.     The  strong  iliosacral  joint  allows  the  ilium  to  tilt  slightly. 

Disjunction  of  the  pubic  symphysis,  necessarily  accompanied  by  sprain 
or  fracture  of  the  sacro-iliac  joint,  is  characterized  by  local  pain,  tender- 
ness, mobility,  tumor  from  blood  effusion,  frequently  urethral  tear, 
indicated  by  bleeding  from  the  meatus,  and  retention  of  urine.     There 


THE  BUTTOCKS  635 

is  usually  history  of  adequate  trauma.  Urinary  retention  is  an  almost 
constant  accompaniment  of  severe  pelvic  injury  in  the  absence  of  urethral 
rupture  or  bladder  lesion. 

Strain  of  the  sacro-iliac  joint  incident  to  sudden  violence,  either  muscular 
or  jarring,  is  characterized  by  local  pain,  exaggerated  by  lateral  pressure 
upon  the  pelvis,  direct  palpation,  or  standing,  jarring  on  the  heels,  and 
motions  of  the  thigh  which  impart  motion  to  the  joint,  as  does  flexion  of 
the  thigh  with  straight  legs.  Recovery  is  usually  prompt.  Symptoms 
incident  to  inadequate  treatment  may  become  chronic,  a  condition  of 
traumatic  arthritis  developing. 

Fractures  of  the  Pelvis. — By  direct  impact  the  crest  of  the  ilium  or 
either  of  the  anterior  spines  may  be  broken,  the  latter  possibly  by  muscular 
force.  The  diagnosis  in  the  absence  of  preternatural  mobility  and 
crepitus  is  suggested  by  persistent  deep  tenderness,  and  is  corroborated 
by  the  a'-rays. 

Deep  fractures,  incident  to  crushing  force,  acting  either  antero- 
posteriorly  or  laterally,  usually  involve  the  pubic  bone,  the  break  passing 
through  both  the  upper  and  the  lower  ramus  and  from  above  down- 
ward and  inward;  sometimes  extending  into  the  acetabulum.  This 
fracture  may  be  comminuted,  bilateral,  may  be  complicated  by  a  fracture 
of  the  ilium  passing  from  its  crest  to  the  sciatic  notch  or  one  at  its  junc- 
tion with  the  sacro-iliac  articulation,  or  more  frequently  by  a  fracture  of 
the  sacrum  paralleling  the  articulations. 

The  diagnosis  is  made  by  palpation,  since  obvious  deformity  is  usually 
absent.  Mobility  and  crepitus  may  often  be  detected  by  external 
palpation  of  the  accessible  surfaces,  supplemented  by  lateral  pressure 
upon  the  iliac  crests  from  without  inward  and  by  separating  them  by 
force  exerted  upon  the  anterior  superior  spines  in  the  outward  direction. 
This  manipulation  in  case  of  fracture  always  occasions  pain,  often 
referred  in  its  greatest  intensity  to  the  sacro-iliac  joint,  which  is  necessarily 
sprained  even  though  there  be  no  fracture  near  it. 

External  examination  should  be  supplemented  by  rectal  palpation,  by 
means  of  which  the  posterior  portion  of  the  pubic  bone  and  its  rami  can 
be  felt. 

x\s  a  result  of  break  in  the  continuity  of  the  pelvic  girdle  there  is  com- 
plete disability,  always  persistently  localized  tenderness  aggravated  by 
motion,  frequently  rupture  of  the  urethra  and  bladder,  characterized  by 
either  the  inability  to  pass  water  or  the  passage  of  bloody  urine  and  late 
discoloration,  which  if  it  appear  above  Poupart's  ligament  is  regarded 
by  Rose  as  of  diagnostic  importance  in  distinguishing  between  intra- 
capsular fracture  of  the  neck  of  the  femur  and  fracture  of  the  acetabulum. 

When  diagnosis  of  fracture  of  the  pubic  bone  is  established,  the  integ- 
rity of  the  urethra  and  bladder  should  be  assured  by  catheterization, 
unless  the  patient  be  able  to  void  urine  unstained  by  blood. 

Osteomyelitis  of  the  Pelvis. — Osteomyelitis  of  the  pelvis  may  occur  in 
the  acute  or  chronic  form,  may  be  diffuse  or  circumscribed. 

Acute  diffuse  osteomyelitis  of  the  ilium  commonly  involves  both  the  hip 
and  the  sacro-iliac  joints,  and  is  attended  with  symptoms  of  violent  sepsis. 


636  THE  LOWER   EXTREMITY 

In  its  circumscribed  form  the  affection  is  often  subacute  or  chronic, 
and  invades  the  acetabular  region  in  young  children,  the  region  of  the 
crest  and  spine  in  older  ones. 

Acute  osteomyelitis  of  the  sacrum  usually  spares  the  sacro-iliac  joint. 

The  sudden  onset  of  symptoms  of  virulent  constitutional  infection 
associated  with  deep  pain,  often  referred  to  the  hip-joint,  and  tender- 
ness are  in  themselves  suggestive.  Edematous  swelling  and  abscess 
formation  are  the  signs  on  which  diagnosis  usually  is  based.  If  the  pro- 
cess be  not  diffuse,  there  may  be  a  subsidence  of  constitutional  and  local 
symptoms  followed  (weeks  or  months)  by  the  appearance  of  a  fluctuating, 
non-inflammatory  tumor  due  to  pus.  Such  cold  abscesses  may  form 
as  a  sequel  of  osteomyelitis  chronic  from  the  first  and  unattended  with 
marked  constitutional  or  local  symptoms. 

The  abscess  of  iliac,  sacro-iliac,  or  acetabular  origin,  if  it  gravitates 
anteriorly,  forms  a  palpable,  often  fluctuating  tumor  closely  attached  to 
the  bone  and  partly  filling  the  iliac  fossa.  It  points  either  just  beneath 
the  outer  part  of  Poupart's  ligament  or  lower  down  the  thigh,  to  either 
side  of  the  sartorius  muscle.  Posterior  pointing  may  be  in  the  gluteal, 
anal,  perineal,  or  upper  posterior  thigh  region. 

Subperitoneal  abscesses  usually  secondary  to  lesions  of  the  cecum, 
appendix,  bladder,  prostate,  or  seminal  vesicles  point  usually  above 
the  inner  third  of  Poupart's  ligament  or  through  the  saphenous  opening. 
Psoas  abscess  points  below  Poupart's  ligament  and  to  the  outer  side  of 
the  bloodvessels. 

Traumatic  inflammation  of  the  sacro-iliac  joint,  characterized  by  pain,  often 
referred  to  as  a  backache,  located  in  the  sacral  region,  and  sequent  on 
slight  injuries  or  overuse,  or  long  maintenance  of  a  position  which  renders 
the  ligaments  tense,  is  diagnosticated  by  tenderness  in  the  joint  elicited  by 
hyperextension  of  the  thigh  on  the  pelvis,  by  attempting  to  extend  the 
leg  on  the  flexed  thigh,  by  directing  the  patient  to  bend  forward  with  the 
knees  straight,  by  all  motions  which  render  tense  the  muscles  of  the  ham, 
and  thus  tilt  the  ilium. 

Sacro-iliac  inflammation,  usually  tuberculous  in  nature,  and  resulting 
in  abscess  formation,  is  rarely  observed  in  children,  nor  is  it  common 
at  any  age.  Its  characteristic  initial  symptom  is  pain  referred  to  or 
near  the  joint,  radiating  over  the  buttock  and  down  the  back  and  inner 
part  of  the  thigh  to  the  knee,  so  greatly  aggravated  by  movement  as  to 
be  crippling  in  intensity,  accompanied  by  a  sense  of  weakness  about 
the  joint,  with  a  distinct  limp  on  walking;  the  body  being  inclined  to 
the  sound  side,  with  apparent  elongation  of  the  affected  leg  incident 
to  the  lowering  of  the  pelvis  on  that  side. 

The  diagnosis  is  based  upon  direct  examination.  With  the  patient  in 
dorsal  decubitus,  squeezing  the  pelvic  brims  together  or  separating  them 
may  give  pain.  In  ventral  decubitus  the  joint  is  tender  to  deep  pressure, 
hyperextension  of  the  thigh  on  the  pelvis  is  limited  and  painful,  the  leg 
cannot  be  straightened  on  the  flexed  thigh,  and  bending  forward  is 
painful. 

Swelling   and    abscess    formation   ultimately   develop    and   may   be 


THE  BUTTOCKS  637 

detected  either  externally  over  the  joint  or  by  rectal  palpation,  though 
the  pus  may  burrow  forward  beneath  the  sheath  of  the  iliacus  muscle 
and  point  in  front  without  being  accessible  to  the  rectal  touch.  When 
the  abscess  breaks  into  the  rectum  or  opens  into  the  rectal  fossa  its  track 
can  usually  be  traced  either  by  probing  or  by  the  injection  of  iodoform 
or  bismuth  and  making  a  picture  with  the  cc-rays. 

The  diagnosis  of  the  tuberculous  nature  of  the  affection  depends  upon 
the  results  of  the  tuberculin  test  and  laboratory  examinations  of  the 
discharge  when  sinuses  have  formed. 

The  distinction  from  disease  of  the  hip-joint  is  made  by  noting  that 
when  the  pelvis  is  fixed  all  motions  of  the  hip-joint  are  free  except  such 
as  put  some  strain  on  the  sacro-iliac  articulation. 

In  the  early  stages  the  elimination  of  low  Pott's  disease  is  difficult. 
The  latter  condition  is  the  usual  one  in  children. 

A  chronically  inflamed  appendix  may  produce  precisely  the  referred 
and  local  pains  of  sacro-iliac  disease,  the  differential  diagnosis  being 
based  upon  the  absence  of  distinct  tenderness  over  the  joint,  the  presence 
of  appendix  tenderness,  and  the  associated  gastro-intestinal  symptoms 
of  appendicitis. 

From  sciatica  the  affection  is  distinguished  by  the  existence  of  local 
tenderness  in  the  joint. 

Rheumatism,  gonorrhea,  syphilis,  and  other  forms  of  infection  may 
manifest  their  presence  by  chronic  inflammation  in  or  near  the  sacro-iliac 
joint. 

Exostoses  originating  in  the  pelvic  bones  are  usually  found  about  the 
sacro-iliac  articulation,  and  exhibit  their  characteristic  slow  growth. 
They  occasionally  develop  on  the  outer  extremity  of  the  acetabulum,  in 
which  case  they  may  interfere  with  motion,  and  if  traumatized  may 
undergo  sarcomatous  degeneration.  The  diagnosis  is  by  palpation,  by 
pressure  symptoms,  expressed  particularly  in  the  form  of  sciatica,  and 
by  the  x-rays. 

Chondromata  (rare),  noted  about  the  iliosacral  joint  and  the  pubic  and 
sciatic  rami,  are  symptomless  except  for  their  bulk  and  the  pressure  symp- 
toms they  may  produce.  The  diagnosis  is  based  upon  the  detection  of  a 
dense,  distinctly  nodular  tumor  which  gives  no  x-ray  shadow.  It  is  cor- 
roborated by  removal. 

Sarcoma,  either  of  the  periosteal  or  central  type,  is  usually  found  in 
the  ilium  to  the  outer  side  of  the  vessels,  and  is  characterized  by  its  rapid 
growth,  early  development  of  pressure  symptoms,  often  by  pulsation. 
Diagnosis  should  be  made  by  the  x-rays  and  by  prompt  removal.  Huge 
tumor,  venous  obstruction,  eggshell  crackling  are  late  signs. 

Pressure  symptoms  are  usually  first  manifested  in  the  form  of  pain, 
which  may  be  sudden  in  onset,  relieved  by  position,  and  becomes  pro- 
gressively worse  with  the  growth  of  the  tumor.  Since  there  may  be 
associated  with  a  rapidly  growing  tumor  a  distinct  fever  with  pronounced 
anemia,  the  disease  may  closely  simulate  a  subacute  or  chronic  osteo- 
myelitis.    The  distinction  can  usually  be  made  by  the  x-rays. 


638  THE  LOWER  EXTREMITY 


THE   INGUINAL  REGION  AND  GROIN. 

The  surgical  affections  peculiar  to  this  region  are  displaced  testicle 
and  affections  of  the  spermatic  cord  or  the  round  ligament. 

Affections  common  in  this  region  are  hernia,  inflammatory  and  neo- 
plastic glandular  enlargements,  varicosities  of  the  lymphatics  or  blood- 
vessels, aneurysm,  and  tumors  or  cysts. 

Undescended  or  misplaced  testicle  forms  an  oval,  smooth,  usually 
movable,  tender  nodule.  Its- nature  is  suggested  by  the  absence  of  the 
gland  from  its  normal  position.  It  is  subject  to  recurring  inflammation 
and  malignant  degeneration,  and  is  often  complicated  by  hernia  (see 
p.  504). 

Hydrocele  of  the  cord,  an  affection  of  infants,  forms  a  fluctuating 
non-inflammatory,  non-sensitive,  translucent  tumor,  moved  by  traction 
on  the  testicle.  It  may  be  partly  or  wholly  reducible.  The  distinction 
from  lipoma  (rare)  or  non-reducible  epiplocele  may  be  difficult,  since 
the  latter  in  infants  exhibits  a  moderate  degree  of  translucency. 

Hydrocele  of  the  round  ligament  exhibits  a  slightly  mobile  tumor  in 
the  inguinal  canal,  partly  reducible,  presenting,  if  large,  through  the 
external  ring.  It  may  be  partly  reducible.  It  is  occasionally  so  closely 
simulated  by  a  cold  abscess  originating  from  the  pubic  bone  that  differ- 
ential diagnosis  is  made  only  on  operation. 

Hernia  is  the  usual  cause  of  inguinal  swelling.  Its  complete  reduci- 
bility  and  the  palpation  of  an  empty  inguinal  or  femoral  canal  there- 
after constitute  the  chief  diagnostic  features. 

Obturator  hernia,  an  affection  of  old  women,  if  it  gives  diagnostic 
symptoms,  will  be  characterized  by  a  swelling  to  the  inner  side  of  the 
bloodvessels,  and  pain  radiating  along  the  course  of  the  obturator  nerve 
and  involving  both  the  hip  and  the  knee.  Careful  palpation  is  needful 
to  make  the  distinction  from  femoral  hernia. 

Gravitation  abscesses  are  reducible  and  exhibit  impulse  on  coughing. 
These  may  be  of  spinal,  sacro-iliac,  pelvic,  or  prostatic  origin. 

Cold  abscesses  of  spinal  origin  form  a  fluctuating  tumor  to  the  outer 
side  of  the  bloodvessels  below  Poupart's  ligament.  By  abdominal 
palpation  the  tumor  can  be  traced  upward  along  the  course  of  the  psoas 
muscle,  and  through  fluctuation  can  be  elicited. 

Cold  abscess  of  sacro-iliac  or  iliac  origin  usually  points  in  the  outer 
part  of  the  groin  below  Poupart's  ligament. 

An  abscess  forming  as  a  result  of  subacute  or  chronic  osteomyelitis 
of  the  pubis  may  readily  simulate  in  position  and  symptomatology  an 
omental  hernia. 

Postperitoneal  cysts,  extravasations,  or  inflammatory  collections  (see 
p.  492),  if  large,  may  point  on  the  inguinal  region  or  groin,  as  does  a 
psoas  abscess. 

Inflammation  of  the  lymphatic  glands  of  the  groin,  if  there  be  no 
demonstrable  focus  on  the  skin  surface  drained  by  them,  should  suggest 
anal  and  urethral  examination.     The  inflammation  incident  to  ordinary 


THE  INGUINAL  REGION  AND  GROIN  639 

infection  may  be  hyperplastic  or  suppurative,  and  is  readily  recognized. 
That  incident  to  chancre  exliibits  characteristic  bilateral  polyglandular, 
painless  enlargement  (see  p.  643). 

Chancroidal  adenitis  frequently  suppurates  and  leaves  persistent  bur- 
rowing sinuses  incident  to  reactionary  inflammation  against  the  necrotic 
gland  substance. 

Tuberculous  adenitis,  by  no  means  uncommon  in  this  region,  exhibits 
the  chronic  course  and  progressive  involvement  of  the  entire  superficial 
group  with  deep  extension,  tendency  to  softening  and  to  sinus  formation, 
and  ultimate  generalization  characteristic  of  the  infection  in  general. 

The  diagnosis  is  based  upon  the  tuberculin  test  and  animal  inoculation. 

Carcinoma  involving  the  inguinal  glands  is  always  secondary. 

Lymphosarcoma  is  marked  by  rapid  and  apparently  causeless  growth, 
without  inflammatory  symptoms  and  exhibiting  a  tendency  to  become 
adherent  to  neighboring  structures.  The  diagnosis  should  be  made  by 
immediate  removal. 

The  enlargements  noted  in  Hodgkin's  disease  are  associated  with 
similar  growths  elsewhere. 

The  cystic  tumor  of  the  lymphatic  gland  due  to  the  filaria  develops  in 
the  superficial  inguinal  group.  The  diagnosis  is  based  upon  associated 
dilatation  of  the  afferent  lymphatic  vessels  and  the  finding  of  the  parasite 
in  the  blood. 

Lymphangioma  may  be  difficult  to  distinguish  from  lipoma  unless 
individual  varices  can  be  felt.  It  is  usually  indefinite  in  outline,  some- 
what nodular,  and  often  congenital. 

Hemangioma  is  usually  associated  with  dilated  skin  vessels  which 
suggest  the  diagnosis.  Its  size  variation  incident  to  position  is  charac- 
teristic. 

Aneurysm  is  usually  unmistakable.  Even  when  inflamed,  and  with  a 
sac  so  extremely  laminated  that  expansile  pulsation  is  not  present,  a  care- 
ful examination  and  a  study  of  the  history  of  the  case  usually  enables  a 
correct  diagnosis  to  be  formulated. 

Tumor  of  the  soft  parts  which  is  not  surely  recognized  as  benign 
should  be  diagnosticated  as  to  nature  by  immediate  operation. 

Exostoses  of  pelvic  origin  may  become  palpable  in  the  groin.  Dense 
consistence  and  slow  growth  suggest  the  diagnosis  which  is  corroborated 
by  the  x-rajs. 

Sarcoma  of  the  pelvic  bones  may  first  become  manifest  by  groin  tumor, 
less  dense  in  structure  than  either  chondroma  or  osteoma,  and  more 
rapid  in  growth.     Diagnosis  is  made  as  by  the  ,r-rays. 


CHAPTER    XVIII. 

THE  GENITO-URINARY  ORGANS. 

The  symptoms  of  surgical  affections  of  the  genito-urinary  organs  are 
visible  or  palpable  alteration  in  position,  size,  or  conformation,  one  or 
all;  disturbance  of  function;  pain  either  localized  or  referred;  and  blood 
or  purulent  discharge  or  both,  appearing  externally  from  a  sore  or  sinus, 
discharging  from  the  urethra  when  the  anterior  part  of  the  mucous 
passage  is  involved  or  found  in  the  urine  when  the  lesion  involves  any 
portion  of  the  urinary  tract  in  or  behind  the  membranous  urethra. 
In  addition  there  may  be  constitutional  symptoms  incident  to  deficient 
elimination  or  septic  absorption. 

THE  PENIS. 

Congenital  Malformations. — This  organ  may  be  absent,  in  which 
case  the  urethra  opens  into  or  near  the  anus,  concealed,  but  discoverable 
by  palpation.  It  may  be  minute,  even  of  quill  size,  gigantic,  double, 
twisted,  or  adherent.  These  rare  deformities  are  obvious.  The  com- 
mon deformities  are  those  associated  with  urethral  defects  (see  p.  666). 

The  prepuce  may  be  deformed,  absent,  adherent,  or  redundant;  excep- 
tionally with  an  orifice  so  small  as  to  constitute  a  source  of  urinary  obstruc- 
tion. It  is  usually  redundant  and  adherent  at  birth.  The  frenum  may 
be  so  short  as  to  interfere  with  erection. 

Trauma  of  the  Penis. — Contusion  is  characterized  by  rapid  swelling 
and  discoloration.  Blood  from  the  urinary  meatus  indicates  partial 
or  complete  rupture  of  the  urethra. 

Wounds. — Wounds  are  of  importance  in  accordance  with  whether  the 
urethra  and  the  erectile  tissue  are  or  are  not  involved. 

Fracture. — Fracture  of  the  penis  due  to  traumatism  exerted  upon  the 
erect  organ  is  due  to  a  tearing  of  the  fibrous  investment  of  the  erectile 
tissue.  It  is  attended  by  severe  pain,  rapid  swelling,  and  subsidence  of 
erection.     Prognosis  as  to  function  without  operation  must  be  guarded. 

Dislocation  of  the  Penis. — ^As  the  result  of  great  force  the  penis  may 
be  squeezed  from  its  skin  investment  as  a  grape  from  its  skin.  The 
sheath  of  the  penis  is  filled  with  blood  clot  closely  simulating  the  flaccid 
organ. 

This  rare  injury  is  usually  complicated  by  rupture  of  the  urethra.  If 
it  be  suspected  the  foreskin  should  be  retracted  until  the  head  of  the  penis 
is  brought  clearly  in  view.  This  is  always  necessary  after  severe  trauma 
of  the  penis  to  determine  the  presence  or  absence  of  urethral  rupture. 


THE  PENIS  641 

Inflammatory  Affections  of  the  Penis. — Diffuse  Inflammations. — The 
envelopes  of  the  penis  are,  aside  from  distinctly  venereal  disorders,  subject 
to  diffuse  inflammations  observed  in  other  parts  of  the  body,  such  as 
dermatitis,  particularly  that  from  rhus  poisoning,  eczema,  pruritus, 
urticaria,  erythema  intertrigo,  stings  of  insects,  erysipelas,  lymphangitis, 
diffuse  cellular  inflammation,  and  gangrene. 

Rhus  dermatitis  is  suggested  by  the  history  of  exposure  and  sudden 
and  rapid  spread  of  the  vesicular  eruption. 

Eczema  is  a  rebellious  affection  usually  involving  both  the  scrotum 
and  the  penis;  gradual  in  onset,  spreading  slowly,  and  exceedingly 
persistent. 

Pruritus  and  erythema  intertrigo  more  commonly  attack  the  scrotum. 

Urticaria. — In  the  absence  of  previous  lesion  a  pronounced,  rapidly 
formed  (hours),  edematous  swelling,  involving  the  skin  and  subcutaneous 
tissues,  not  interfering  with  the  function  of  urination  except  by  edematous 
phimosis,  and  not  spreading  peripherally,  is  likely  to  be  urticarial  (acute 
rheumatism,  gastro-intestinal  disturbances). 

Erysipelas. — If  an  acute  swelling  has  been  preceded  by  surface 
lesions  such  as  those  of  balanoposthitis,  and  it  exhibits  a  tendency  to 
spread  from  the  root  of  the  penis  over  the  abdomen  and  thighs,  particu- 
larly if  it  is  associated  with  the  constitutional  symptoms  of  septic  absorp- 
tion, has  raised  borders,  and  is  accompanied  by  enlargement  of  the 
inguinal  glands,  the  affection  is  probably  erysipelas. 

Cellulitis. — If  the  swelling  has  been  preceded  by  difficulty  in  micturi- 
tion and  induration  along  the  course  of  the  urethra,  and  in  its  progression 
involves  the  penis,  the  scrotum,  and  thence  spreads  directly  upward  on  the 
abdominal  walls,  sparing  the  anal  perineum  and  upper  part  of  the  thighs, 
urinary  extravasation  should  be  suspected  and  examined  for. 

Cavernitis. — If  the  swelling  is  associated  with  marked  deep  induration 
and  profound  constitutional  symptoms  of  septic  absorption,  involve- 
ment of  the  erectile  tissue  should  be  suspected,  usually  secondary  to 
extravasation.  When  the  inflammation  has  proceeded  to  gangrene  the 
diagnosis  is  sufficiently  obvious. 

Lymphangitis  in  its  acute  form  is  always  secondary  to  an  infected  lesion, 
and  is  characterized  by  an  edematous  swelling  of  the  skin  of  the  penis 
and  the  presence  of  an  indurated  tender  cord  in  the  position  of  the  dorsal 
lymphatic  vessels,  movable  with  the  skin  over  the  deeper  parts.  The 
inguinal  glands  are  enlarged.     Small  dorsal  abscesses  may  form. 

Phlebitis  (rare)  is  attended  with  symptoms  characteristic  of  lym- 
phangitis, except  that  the  induration  is  more  deeply  placed  and  the 
inguinal  lymphatic  glands  are  not  necessarily  enlarged. 

Circumscribed  inflammation  of  the  penis  may  be  non-ulcerating  or 
ulcerating. 

The  non-ulcerating  inflammatory  circumscribed  lesions  of  the  penis  are 
itch,  papular  syphilitic  eruptions,  exceptionally  chancre,  and  paraphimosis. 
With  the  exception  of  the  chancre,  lesions  of  a  similar  nature  on  other 
parts  of  the  body  suggest  the  diagnosis,  though  itch  may  occur  only  on 
the  penis.  The  detection  of  the  burrow  under  a  magnifying  glass  and 
41 


642  THE  GENITO-URINARY  ORGANS 

the  finding  of  the  insect  or  the  effect  of  sulphur  treatment  would  be 
conclusive. 

When  chancre  appears  as  a  papule  which  does  not  ulcerate,  a  history 
of  exposure  to  infection  not  less  than  twelve  days  before  the  appear- 
ance of  the  lesion,  the  development  of  induration  (five  days),  inguinal 
adenopathy,  and  resistance  to  treatment  should  suggest  a  diagnosis 
which  could  be  formulated  by  excision  and  microscopic  examination  of 
the  papule. 

Paraphimosis,  characterized  by  edematous  swelling  of  the  foreskin 
beyond  the  ring  of  constriction  formed  by  a  tight  preputial  orifice  drawn 
behind  the  glandular  corona  is  usually  obvious  on  inspection.  Excep- 
tionally the  prepuce,  in  place  of  turning  back  as  the  sleeve  of  a  coat, 
and  causing  edema  of  its  mucous  surface,  slips  directly  over  the  corona 
and  causes  rapid  swelling  of  the  glans.  In  such  a  case  the  ring  of  con- 
striction may  be  picked  up  by  a  grooved  director  passed  from  before 
backward  in  the  sulcus.  When  the  prepuce  is  rolled  back  the  constriction 
ring  must  be  picked  up  by  the  director  passed  from  behind  forward. 

Eroded  or  ulcerating  circumscribed  inflammatory  lesions  of  the  penis 
include  balanoposthitis,  simple  hair  cuts  or  abrasions,  herpes,  chancre, 
secondary  and  tertiary  lesions  of  syphilis,  chancroid,  tuberculous  ulcera- 
tion, and  epithelioma. 

The  commonest  of  these  lesions  are  those  of  balanoposthitis  and  simple 
infection  from  slight  trauma.  In  private  practice  chancroid  is  less 
frequent  than  are  the  syphilitic  lesions.  Tuberculous  lesions  are 
exceedingly  rare. 

Paraphimosis  in  its  advanced  stage  may  be  attended  with  deep  ulcera- 
tion at  the  point  of  constriction  or  even  extensive  gangrene  of  the  glans 
and  foreskin. 

Balanoposthitis,  predisposed  to  by  a  long,  tight  prepuce,  the  gouty  or 
rheumatic  diathesis,  and  abnormal  conditions  of  the  urine,  often  excited 
by  a  urethral  discharge  or  one  from  an  ulcerating  lesion  of  the  glans  or 
prepuce,  is  characterized  by  itching,  heat,  swelling,  and  an  offensive, 
irritating  discharge.  The  slightly  edematous  prepuce,  being  stripped 
back,  shows  areas  of  denudation  covered  with  a  thick,  creamy  discharge. 
There  may  even  be  distinct  excoriations  and  superficial  ulcers.  These 
lesions  may  be  the  starting  point  of  lymphangitis,  phlebitis,  or  cellulitis. 
They  often  precede  the  development  of  condylomata. 

This  is  a  common  inflammation  in  children  and  in  adults  who  do  not 
keep  the  preputial  sac  clean. 

The  inflammation  may  be  a  manifestation  of  secondary  syphilis,  in 
which  case  there  will  be  other  signs  of  the  constitutional  disease,  nor  will 
cleansing  treatment  avail. 

Chancroid  may  begin  as  a  balanoposthitis.  The  diagnosis  can  be 
made  only  by  the  further  development  of  the  latter  lesion.  The  distinction 
from  herpes  is  dependent  upon  the  beginning  of  the  latter  in  the  form 
of  discrete  vesicles  which  become  confluent  with  circinate  borders. 
These  lesions  may  be,  however,  quickly  complicated,  often  completely 
obscured,  by  balanoposthitis. 


THE  PENIS  643 

In  the  presence  of  phimosis  the  diagnosis  of  simple  balanoposthitis 
may  be  extremely  difficult.  The  absence  of  the  gonococcus  excludes 
gonorrhea;  of  induration  probably,  but  not  certainly,  chancre;  prompt 
yielding  to  cleansing  treatment,  chancroid. 

If  the  inflammatory  symptoms  are  persistent  or  progressive,  incision 
will  be  needful  for  the  framing  of  a  diagnosis. 

Cracks,  fissures,  hair  cuts,  and  abrasions  contaminated  by  the  ordinary 
pus  organisms  represent  the  commonest  form  of  genital  sores.  These 
become  obvious  within  twenty-four  hours  of  the  time  of  infection.  Symp- 
toms of  local  inflammation  increase  for  two  or  at  most  three  days  and 
then  rapidly  subside  under  ordinary  cleansing  treatment.  On  this 
point  the  early  diagnosis  from  chancroid  and  chancre  must  be  made. 

From  herpes  these  simple  infections  are  distinguished  by  the  fact  that 
they  do  not  appear  first  as  vesicles  or  superficial  round  sores.  They 
conform  in  shape  to  the  original  lesion,  usually  a  scratch  or  hair  cut  or 
an  irregular  abrasion. 

Herpes  is  characterized  by  the  somewhat  sudden  appearance  of  vesicles 
with  erythematous  bases  situated  on  the  mucous  or  skin  surfaces  of  the 
penis.  They  are  attended  with  itching  and  burning  and  are  prone  to 
recur.  They  are  commonly  found  about  the  coronary  sulcus,  involving 
both  the  glans  and  foreskin.  The  vesicles  are  quickly  macerated,  leaving 
round  or  irregular  erosions  tending  to  become  rapidly  confluent.  There 
is  associated  surrounding  balanoposthitis.  At  times  there  is  intense 
pain,  which  may  be  accompanied  by  urethral  discharge  because  of 
similar  lesions  in  the  urethra. 

Herpes  is  characterized  by  its  tendency  to  recur,  sudden  appearance 
in  clusters  of  vesicles,  usually  in  the  absence  of  obvious  cause,  absence 
of  induration,  superficial  nature  of  the  eruption,  circinate  border  of  the 
confluent  lesion,  and  rapid  healing  of  the  outbreak  under  cleansing 
treatment,  though  fresh  crops  may  appear.  There  is  often  bilateral, 
polyglandular,  inguinal  induration. 

Exceptionally  chancre  begins  as  herpes.  The  diagnosis  must  be 
based  upon  the  persistence  of  the  original  lesions,  the  tendency  to 
induration,  and  microscopic  examination. 

Chancre. — Chancre  forms,  usually  one,  often  two  or  more,  indolent, 
indurated  erosions  or  ulcerations.  Any  macule,  slight,  painless  excoria- 
tion, or  scratch,  which  persists  in  spite  of  careful  local  treatment,  which 
slowly  spreads  without  marked  inflammatory  symptoms,  which  becomes 
distinctly  hard  peripherally  and  at  the  base  as  though  there  were  a  dense, 
cellular  infiltrate,  and  which  gives  a  thin,  scanty  discharge,  showing  a 
tendency  to  crust  or  to  form  a  pseudomembranous  deposit  covering  the 
excoriated  surface,  is  almost  certainly  a  chancre. 

The  diagnosis  is  further  strengthened  by  proof  of  exposure,  an 
incubation  period  of  two  to  five  weeks,  progressive  hardening  of  the 
dorsal  lymphatic  vessels,  and  induration  of  one  or  more  of  the  inguinal 
lymphatic  glands,  usually  two  or  three  on  each  side.  From  mixed 
ififection  these  glands  may  suppurate.     This  is  exceptional. 

Long   incubation,    persistent    induration,    and    progressive   inguinal 


644  THE  GENITO-URINARY  ORGANS 

adenopathy  are  more  characteristic  than  the  form  of  the  lesion,  which  is 
usually  oval  or  round,  but  may  begin  as  a  balanoposthitis  and  continue 
as  such  except  for  hardening  of  the  foreskin. 

Fig.  427 


Meatal  chancre.  Incubation,  three  weeks.  Duration,  four  weeks.  Ulcerating  surface  covered  by 
pseudomembrane  within  the  meatus.  Inguinal  glands  tjTjically  enlarged.  Urination  obstructed, 
and  occasionally  bleeding  from  the  meatus. 

Fig.  428 


Chancre  of  the  glans  sulcus  and  inner  preputial  surface.  The  typical  induration  causes  it  to 
project  in  place  of  lying  flat  when  the  foreskin  is  retracted.  Incubation,  three  weeks.  Duration, 
three  weeks.  A  flat,  superficial,  indolent,  rounded  sore.  Wire-like  induration  of  the  dorsal 
lymphatics  of  the  penis.     Glands  in  each  groin  painlessly  enlarged. 


THE  PENIS 


645 


The  induration  may  be  simulated  by  the  inflammatory  infiltration 
incident  to  cauterization  of  a  non-specific  sore,  or  by  that  of  a  slowly 
forming  furuncle  or  a  folliculitis.  A  gumma,  or  so-called  relapsing 
chancre,  may  so  closely  simulate  a  primary  lesion  that  differential 
diagnosis  must  be  based  upon  the  history,  since  both  induration  and 
inguinal  adenopathy  may  be  absent  from  chancre  (exceptional). 

The  finding  of  the  spirocheta  in  the  scrapings  of  an  excised  sore 
constitutes  the  only  absolutely  conclusive  early  diagnostic  sign  of  chancre. 

Secondary  and  Tertiary  Lesions  of  Syphilis. — The  secondary  eruption 
of  syphilis,  particularly  in  the  form  of  mucous  patch,  is  common  on 
the  penis  and  foreskin.  It  is  usually  associated  with  a  recent  history 
of  syphilis  and  other  unmistakable  lesions  of  the  disease. 

Gumma  is  prone  to  develop  at  or  near  the  seat  of  a  former  chancre; 
it  begins  as  an  induration  which  softens  and  discharges,  forming  a  hard, 
indolent,  deep  ulcer,  often  mistaken  for  chancre.  The  inguinal  glands 
are  not  characteristically  enlarged  nor  do  secondary  eruptions  develop. 


Fig.  429 


Chancroids.     Incubation,  twenty-four  hours.      Duration,  five  days      Multiple    acutely  inflamma- 
tory, freely  suppurating,  punched-out  destructive  lesions. 

Chancroid. — Chancroid  usually  begins  exactly  as  a  simple  abrasion  or 
hair  cut,  hence  is  without  incubation,  but  may  not  become  sufiiciently 
obvious  to  attract  attention  for  three  to  five  days  after  exposure.  The 
lesion  may  be  single  and  so  remain  throughout.  It  is  usually  multiple 
and  successively  so,  i.  e.,  fresh  sores  break  out  in  crops.  Chancroids 
progress  rapidly,  forming  ragged,  punched-out,  often  undermined,  non- 
indurated  ulcers,  irregular  in  shape,  discharging  freely,  inflammatory 
in  type,  covered  with  a  gray,  pus-soaked  slough  or  concealed  by  a  thick, 
moist  scab.     They  produce  similar  lesions  on  surfaces  with  which  they 


646  THE  GENITO-URINARY  ORGANS 

come  into  contact.  Their  discharge  can  be  inoculated  on  anj  portion 
of  the  surface  of  the  body.  In  the  later  stage  of  their  course  (three 
weeks)  auto-inoculation  fails. 

Exceptionally  chancroids  exhibit  induration,  particularly  those  which 
have  been  cauterized. 

A  chancroid  may  become  gangrenous  if  it  be  complicated  by  phimosis 
or  paraphimosis,  or  if  it  be  mechanically  or  chemically  irritated. 

The  distinction  from  simple  infection  and  balanoposthitis  is  impossible 
if  the  chancroid  be  seen  at  its  very  beginning.  Later  it  is  based  upon  the 
ulcerating,  rapidly  extending  type  of  inflammation  and  the  finding  of 
the  Ducrey  bacillus. 

Ulcerating  gummata  ultimately  produce  lesions  indistinguishable 
in  appearance  from  chancroid.  Induration  precedes  destruction,  and 
this  process  is  a  matter  of  weeks  or  months. 

Tuberculous  ulcers  are  extremely  slow,  associated  with  tuberculous 
lesions  elsewhere,  may  exhibit  peripherally  semitransparent,  grayish, 
miliary  tubercles,  and  scrapings  show  the  bacilli  microscopically. 

Epitheliomatous  ulcer  is  a  common  malignant  infiltration  of  the  penis, 
usually  beginning  as  a  wart  in  a  middle-aged  or  elderly  man,  at  times 
before  the  thirtieth  year.  The  mere  presence  of  a  persistently  (weeks) 
ulcerating  wart,  not  obviously  syphilitic,  calls  for  immediate  excision  and 
microscopic  examination.  Thus  only  can  the  diagnosis  be  made  at  a 
time  when  it  is  serviceable. 

The  well-developed,  ulcerating,  and  fungating  epithelioma  is  unmis- 
takable. Glandular  involvement  and  widespread  infiltration  of  tissue 
will  sufficiently  distinguish  it  from  broken-down  gumma. 

Tuberculous  ulcers  are  rare.  They  are  associated  with  obvious  tuber- 
culous lesions  elsewhere,  are  exceedingly  chronic  in  course,  and  may 
exhibit  about  their  periphery  characteristic  miliary  tubercles.  Finding 
the  tubercle  bacillus  would  be  diagnostic. 

Abscess  of  the  Penis, — This  exceptionally  takes  the  form  of  an  ordinary 
boil. 

Usually  it  is  due  to  a  folliculitis  in  turn  secondary  to  urethritis.  Along 
the  course  of  the  urethra  can  be  felt  one  or  more  hard,  tender,  pea-sized 
nodules  which  usually  discharge  into  the  urethra.  If  the  duct  leading 
thereto  be  blocked,  the  swelling  becomes  red  and  soft,  and  there  is  an 
external  discharge  of  pus.  These  abscesses  are  commonest  along  the 
course  of  the  bulbous  urethra  and  near  the  meatus,  on  one  or  both  sides 
of  the  frenum.  Exceptionally,  they  give  rise  to  urinary  extravasation; 
or  opening  both  internally  and  externally,  form  fistulse.  In  the  latter 
case  the  course  of  the  tract  is  often  indirect,  and  the  urethral  opening 
may  be  in  the  roof  of  this  canal. 

Tumors  of  the  Penis. — Papilloma. — -Papilloma  is  the  commonest 
tumor  of  the  penis.  It  may  be  single  or  multiple,  confluent  or  discrete, 
moist  or  dry. 

Commonly  it  springs  from  the  coronary  sulcus,  posterior  border  of  the 
glans  penis,  margin  of  the  prepuce,  the  region  of  the  frenum,  and  the 
orifice  of  the  urethra,  and  is  frequently  sequent  to  urethral  discharge 


THE  PENIS  647 

or  balanoposthitis.     Redundant  or  phimotic  foreskin  is  the  usual  pre- 
disposing factor. 

With  the  condyloma  latum,  or  mucous  patch,  a  wart  may  readily  be 
confounded.  The  former  represents  a  papillary  outgrowth  due  to  irrita- 
tion of  the  spirocheta  or  its  products.  Diagnosis  will  be  based  upon  the 
history  of  the  case  and  concomitant  lesions.  Moreover,  the  syphilitic 
lesion  never  attains  the  enormous  outgrowth  characteristic  of  the  wart. 

Fig.  430 


Epithelioma  of  penis.  Cauliflower  (fungating)  mass  involving  glans  and  prepuce.  One  year's 
duration.  Edema  of  dependent  portion  of  prepuce.  Bilateral  enlargement  of  inguinal  lymph 
glands.     (Carnett.) 

Epithelioma. — Epithelioma,  beginning  as  an  ulcerating  papilloma,  is 
diagnosticated  by  excision  and  microscopic  examination. 

Among  rare  tumors  of  the  penis  may  be  mentioned  sarcoma;  der- 
moid, sebaceous,  blood,  and  mucous  cysts;  horny  growths;  fibroma; 
adenoma;  lymphangioma.  These  tumors  coincide  in  development  and 
appearance  with  similar  lesions  placed  elsewhere.  Cysts  of  Tyson's 
glands  may  be  multiple  and  reach  a  large  size. 

Distressing  bladder  reflexes  have  been  noted  in  connection  with 
angiomata. 

Sarcoma. — Sarcoma,  at  times  melanotic,  when  originating  f^-om  the 
glans  appears  as  a  rounded  nodule,  growing  from  the  erectile  tissue  or 
its  sheath,  elastic,  clearly  outlined,  increasing  rapidly  in  size,  and 
markedly  interfering  with  erection.  If  gumma  can  be  excluded  and 
the  small  growth  from  its  position  cannot  possibly  be  an  expression  of 
chronic  folliculitis,  the  diagnosis  should  be  made  at  once  by  excision 
and  microscopic  examination. 

Lymphangioma,  or  elephantiasis,  which  occurs  about  the  external 
genitals,  involves  both  the  penis  and  scrotum.  In  this  country  it  is  usually 
secondary  to  disease  or  removal  of  the  inguinal  lymphatics. 


648  THE  GENITO-URINARY  ORGANS 

~  Dermoid  cysts,  congenital  in  origin,  usually  placed  in  the  raphe,  form 
non-inflammatory  tumors,  which  after  years  of  indolence  may  grow 
rapidly.     They  are  diagnosticated  by  removal  and  examination. 

Induration  of  the  Cavernous  Bodies. — On  the  dorsum  of  the  penis 
of  middle-aged  men  may  rarely  be  found  on  palpation  one  or  more 
irregularly  shaped,  indurated  areas,  cartilaginous  in  hardness,  usually 
neither  tender  nor  painful,  and  causing  marked  distortion  on  erection. 
There  is  no  visible  tumor,  and  the  overlying  skin  is  freely  movable. 
This  condition  is  associated  with  the  gouty  and  rheumatic  diathesis,  and 
is  distinguished  from  gumma  by  its  chronicity,  its  occurrence  in  the 
absence  of  signs  of  syphilis,  and  the  fact  that  it  never  breaks  down. 

Functional  Disturbances  of  the  Penis. — Erection  may  be  absent, 
partial,  complete,  or  persistent. 

Absence  of  erections  may  be  due  to  developmental  failure,  exception- 
ally of  the  penis,  more  commonly  of  the  testicles.  It  is  a  sequel  of 
degeneration  or  removal  of  the  testes,  prolonged  priapism,  and  may 
follow  complete  prostatectomy.  It  is  a  constant,  often  an  early,  symptom 
of  degenerations  of  the  cord,  particularly  that  of  which  locomotor  ataxia 
is  an  expression. 

Absent  or  feeble  erections  are  usually  due  to  a  lumbar  cord  neuras- 
thenia incident  to  chronic  inflammation  of  the  posterior  urethra,  pro- 
longed, ungratified  sexual  excitement,  sexual  excess,  or  general  neuras- 
thenia. The  diagnosis  is  incident  to  the  history  and  a  urethral  and 
neurological  examination. 

Priapism,  or  prolonged  erection,  unaccompanied  by  sexual  desire, 
often  painful,  may  be  intermittent  or  persistent. 

In  its  intermittent  form  it  is  sometimes  an  early  sign  of  spinal  degenera- 
tion. Usually  it  indicates  a  source  of  irritation  about  the  urethra,  penis, 
or  anus.  At  times  it  follows  venereal  excess.  Exceptionally  it  is  appar- 
ently idiopathic,  coming  on  at  night,  and  giving  rise  to  but  little  incon- 
venience aside  from  the  psychical  effect  it  produces.  It  is  little  influ- 
enced by  treatment,  nor  do  these  cases  ultimately  develop  symptoms 
that  would  suggest  that  this  recurring  priapism  is  of  evil  portent. 

Persistent  priapism  is  a  common  symptom  of  leukemia,  a  rare  one  of 
locomotor  axaxia  and  syphilis  of  the  cord,  and  a  very  exceptional  sequel 
of  perineal  trauma. 

The  etiology  is  at  times  undiscoverable.  It  may  last  weeks  or  months. 
Turgescence  is  limited  to  the  cavernous  bodies,  urination  is  likely  to  be 
somewhat  difficult,  and  the  ultimate  result  is  sclerosis  of  the  erectile 
tissue  and  incurable  impotence. 

THE  SCROTUM. 

Congenital  deformities  are  unknown,  except  in  association  with  other 
lesions  of  the  external  genitalia.  In  hypospadia  and  hermaphrodism 
there  is  cleft  scrotum.  The  penis  and  scrotum  may  be  grown  together. 
In  the  case  of  undescended  testicle  the  scrotum  remains  infantile  or  un- 
developed. 


THE  SCROTUM 


649 


Contusions. — Contusions  are  followed  by  rapid  swelling  and  intense 
discoloration. 

Edema.— Edema  is  a  common  expression  of  either  general  vascular 
failure  or  local  inflammation.  In  the  former  case  it  is  associated  with  a 
similar  condition  elsewhere,  and  the  symptoms  of  local  inflammation  are 
absent.  Its  presence,  when  not  traumatic,  or  secondary  to  surface  lesion, 
should  suggest  extravasation  of  urine. 

Emphysema. — Emphysema,  if  not  artificially  produced,  is  indicative  of 
extravasation  and  extensive  sloughing. 

Cutaneous  Affections. — These  exhibit  the  characteristics  of  such  lesions 
when  placed  in  other  parts  of  the  body.  Those  of  inflammatory  nature 
common  on  the  scrotum  are  erythema  intertrigo  and  eczema;  of  para- 
sitic nature,  pediculosis;  of  cystic  nature,  molluscum  contagiosum  and 
sebaceous  cysts. 

Fig.  431 


Eczema  rubrum  of  the  scrotum.     (Hartzell.) 


Circumscribed  erosions  or  ulcers  of  the  scrotum,  if  not  traumatic,  are 
chancre,  chancroid,  or  the  lesions  of  secondary  or  tertiary  syphilis. 

Abscesses  and  sinuses  are  secondary  to  urethral  extravasation  or  simple 
infection,  or  tuberculous,  syphilitic,  or  malignant  degeneration  of  the 
testicle. 

Cellulitis  may  be  secondary  to  a  wound  or  granulating  surface.  It 
is  usually  an  expression  of  urinary  extravasation  or  abscess  rupturing 
into  the  scrotal  tissue. 

Erythema  intertrigo  is  frequent  in  children  and  in  fat,  flabby  men,  espe- 
cially those  who  are  rheumatic  or  uncleanly,  or  both,  or  who  readily  chafe. 

Eczema  is  commonly  associated  with  gout,  rheumatism,  and  diabetes. 
It  may  occur  in  any  of  its  forms,  causing  great  itching,  burning,  and  when 
persistent  a  marked  thickening  of  the  scrotal  tissues. 


650 


THE  GENITO-URINARY  ORGANS 


Pruritus,  most  frequently  noted  in  the  rheumatic,  may  develop  inde- 
pendently of  any  local  lesion  and  reach  maddening  intensity.  The  only 
symptom  is  itching,  which  may  produce  so  great  a  yearning  to  scratch, 
pull,  and  knead  the  scrotum  that  decorum,  even  decency,  is  forgotten. 

Pediculosis  is  the  usual  cause  of  itching  unassociated  with  pronounced 
skin  lesions. 

Diagnosis  is  made  by  finding  the  lice  which  resemble  small  skin  scabs 
and  are  most  abundant  at  the  root  of  the  penis.  The  ova,  looking  like 
flakes  of  dandruff,  but  rounded  and  intimately  adherent  to  the  hair,  can 
readily  be  found  if  search  be  made  for  them. 


Fig.  432 


Elephantiasis  of  scrotum.  Ten  years'  duration.  Filaria  sanguinis  hominis  never  found.  Charac- 
teristic thickening  and  corrugation  of  the  skin.  Hyperplasia  of  the  subcutaneous  tissues.  Pre- 
putial orifice  near  middle  of  tumefaction.     (Carnett.) 

Molluscum  contagiosum  is  usually  seen  in  children.  Small,  waxy, 
almost  spherical  tumors  or  cysts  are  found  in  the  superficial  layers  of 
the  skin,  mostly  sessile,  sometimes  pedunculated,  later  they  become 
umbilicated,  showing  a  small,  black  spot  in  the  centre  indicating  the 
opening  into  the  follicle.     They  are  painless. 

Sebaceous  cysts  are  usually  single,  forming  soft,  doughy,  rounded 
tumors  in  the  skin.  In  the  adult  they  may  reach  the  size  of  an  egg 
and  are  prone  to  break  down  and  suppurate. 

Chancre,  chancroid,  mucous  patch,  gumma,  and  epithelioma  of  the 
scrotum  exhibit  no  departure  from  type. 

Abscess  of  the  Scrotum. — ^Abscess  of  the  scrotum  presents  characteristic 
features,  the  edematous  swelling  being  particularly  well  marked  and 
fluctuation  occurring  early.     Except  those  from  a  breaking  down  hema- 


4 

THE  TESTICLE  AND  EPIDIDYMIS  651 

toma  or  suppurating  sebaceous  cyst,  such  abscesses  are  of  urethral, 
testicular,  or  rectal  origin,  hence,  after  discharge,  sinuses  remain  which 
may  be  multiple  or  greatly  infiltrated. 

Cellulitis  of  the  Scrotum. — ^This,  exceptionally  traumatic,  occasionally 
due  to  extension  of  skin  infection,  is  usually  a  sign  and  symptom  of 
urinary  extravasation.  The  edema  is  deep  and  infiltrating,  there  are 
constitutional  signs  of  infection  (exceptionally  none),  and  the  preceding 
and  accompanying  symptoms  of  urethral  obstruction. 

Tumors  of  the  Scrotum. — These,  if  sebaceous  cyst  be  excepted, 
are  rare. 

Epithelioma  begins  as  an  indurated  wart,  which  becomes  ulcerated, 
scabs  on  its  surface,  and  is  characterized  by  hard,  raised  edges,  uneven 
surface,  and  the  exudation  of  ichorous  pus.  The  distinction  from  syphi- 
litic lesion,  when  this  is  in  doubt,  should  be  made  by  excision  and 
inicroscopic  examination. 

Lipoma  sometimes  develops.  It  may  be  infiltrating  or  globular. 
Usually  the  former.  Diagnosis  is  based  upon  the  consistency.  Distinction 
from  omental  hernia  may  be  extremely  difficult,  indeed  quite  impossible 
if  the  tumor  has  infiltrated  along  the  course  of  the  cord. 

Lymphangioma  or  lymphedema,  usually  secondary  to  inflammation 
or  removal  of  the  inguinal  lymphatics,  and  characterized  by  a  brawny 
induration  and  enormous  thickening,  may  reach  huge  proportions.  The 
diagnosis  is  obvious. 

Gummata,  enchondromata,  osteomata,  and  fibromata  are  occasionally 
observed. 

THE  TESTICLE  AND  EPIDIDYMIS. 

Congenital  Anomalies. — -The  testicle  may  be  absent,  fused,  enlarged, 
inverted,  arrested  in  development,  imperfectly  descended,  or  displaced 
from  its  normal  position  or  its  track  of  descent. 

The  testicle  may  be  absent  on  one  or  both  sides.  In  the  latter  case 
the  diagnosis  is  based  upon  impotence  and  asexuality;  hence,  it  is  a 
matter  of  time.     Complete  absence  of  the  testes  is  exceedingly  rare. 

The  testicle  may  be  arrested  at  any  point  in  its  transit. 

Abdominal  Retention. — Abdominal  retention  may  be  unilateral  or 
bilateral,  the  testicle  may  be  found  close  to  the  posterior  abdominal 
wall,  below  the  kidney,  may  be  provided  with  a  long  mesorchium, 
allowing  it  to  move  freely  in  the  abdominal  cavity,  or  it  may  be  placed 
in  the  iliac  fossa  close  to  the  internal  ring. 

Inguinal  Retention. — The  testicle  may  be  arrested  at  the  internal  ring, 
in  the  inguinal  canal,  or  at  the  external  ring,  and  is  usually  extremely 
mobile,  unless  it  becomes  fixed  by  attacks  of  inflammation. 

Cruro scrotal  Retention. — In  incomplete  scrotal  descent  the  testicle  lies 
outside  of  the  inguinal  canal,  but  fails  to  descend  completely,  being 
found  in  the  fold  between  the  scrotum  and  the  thigh,  at  a  varying  dis- 
tance from  the  ring. 

If  the  testicle  takes  an  aberrant  course,  it  may  be  found  beneath  the 
skin  of  the  abdominal  wall  at  a  variable  distance  from  the  external 


652  THE  GENITO-URINARY  ORGANS 

abdominal  ring,  in  the  crural  region  behind  the  femoral  vessels,  or 
in  the  perineum. 

Incomplete  transit  is  most  commonly  manifested  in  the  form  of  in- 
guinal retention;  the  aberrant  transit,  in  the  form  of  perineal  ectopy. 

Diagnosis  of  misplaced  testicle  is  based  upon  the  absence  of  the  gland 
from  its  normal  position  and,  excepting  in  abdominal  ectopy,  the  finding 
of  it  elsewhere.  The  scrotum  is  atrophic  on  the  side  of  the  displacement. 
In  children  the  testis  is  extremely  small  and  very  movable,  and  to  the 
unpractised  finger  not  always  readily  found.  The  testis  which  is  not 
descended  by  the  sixth  year  will  usually  remain  in  its  faulty  position 
unless  subjected  to  surgical  treatment. 

A  testis  abnormally  placed  does  not  reach  full  size,  nevertheless 
it  may  secrete  healthy  spermatozoa  unless  it  be  subject  to  repeated 
inflammation. 

Misplaced  testicle  is  often  complicated  by  hernia  of  the  congenital 
or  funicular  type  exhibiting  the  characteristic  symptoms  of  hernia. 

Orchi-epididymitis,  particularly  the  traumatic  and  urethral  form,  is 
a  common  complication,  exhibiting  symptoms  which  depart  from  type 
only  in  their  location.  Such  an  affection  in  the  case  of  abdominal  or 
inguinal  ectopy  might  closely  simulate  internal  strangulation  of  hernia 
and  be  mistaken  for  such  if  absence  of  the  testis  were  unsuspected,  since 
tympany  and  vomiting  are  common  reflexes  of  testicular  inflammation. 

Torsion  is  an  accident  to  which  the  undescended  testis  seems  pecu- 
liarly subject.  The  symptoms  are  those  of  a  hyperacute  orchi-epididy- 
mitis. Nor  can  the  diagnosis  be  made  with  absolute  certainty  without 
incision. 

Hydrocele  and  hematocele  exhibit  symptoms  elsewhere  described  but 
for  their  unusual  position.  The  congenital  hydrocele,  slowly  reducible 
into  the  abdominal  cavity,  must  be  distinguished  from  omental  hernia 
by  marked  translucence,  slow  and  gradual  reduction,  equally  slow  return, 
and  finally  by  incision. 

Malignant  degeneration  exhibits  a  solid  tumor  in  the  inguinal  region, 
steadily,  often  rapidly  progressive,  accompanied  bypersistent  pain.  The 
diagnosis  must  be  made  through  an  incision,  since,  when  it  is  obvious 
from  nodulation,  great  size,  and  adherence  of  the  tumor,  operation  is  of 
no  avail. 

Inversion  of  the  Testicle. — Though  it  may  descend  to  the  bottom  of 
the  scrotum,  the  testicle  may  exhibit  anterior,  horizontal,  or  lateral  dis- 
placement, or  may  be  completely  rotated,  the  epididymis  lying  in  front, 
the  free  border  to  the  rear.  The  possibility  of  this  displacement  must 
be  considered  in  tapping  for  hydrocele. 

Affections  of  the  Testicle  and  Epididymis  Characterized  by  Acute 
Inflammatory  Phenomena. — Torsion  of  the  testicle  may  be  either  to  the 
right  or  to  the  left,  and,  in  accordance  with  its  extent  and  the  degree  of 
constriction  to  which  the  vessels  are  subject,  the  symptoms  are  slight  or 
severe.  In  slight  cases  the  epididymis  alone  becomes  infiltrated.  In 
severe  cases  the  entire  gland  with  the  epididymis  becomes  gangrenous. 

The  symptoms  of  torsion  are  those  of  orchi-epididymitis  of  a  hyper- 


THE  TESTICLE  AND  EPIDIDYMIS  653 

acute  type  appearing  suddenly  and  causelessly  during  active  muscular 
exertion.  Attacking  an  undescended  testis,  the  symptoms  are  akin  to 
those  of  internal  strangulation.  In  any  case  the  diagnosis  can  be  made 
only  by  incision. 

Contusion  of  the  Testicle. — Acute  traumatic  orchi-epididymitis  is  char- 
acterized by  sickening  pain  so  severe  as  to  cause  syncope,  sometimes 
death.  The  testicle  is  retracted  and  there  is  rapid  swelling.  The 
pain,  at  first  overwhelming,  is  followed  by  a  constant  ache  aggravated 
by  standing,  coughing,  or  straining,  and  so  wearing  as  to  enjoin  anodynes 
and  rest  in  bed;  subsiding  in  three  to  five  days,  and  leaving  a  testis 
prone  to  atrophy. 

Acute  epididymoorchitis  from  strain  properly  belongs  to  contusion, 
since  the  injury  inflicted  on  the  testicle  is  incident  to  the  sudden  jerk 
on  the  part  of  the  cremaster  muscle,  or  to  blood  effusion  incident  to  the 
venous  congestion  of  abdominal  strain. 

A  descending  infection  often  follows  hard  upon  a  strain.  The  onset 
is  not  sudden,  and  such  cases  usually  assume  the  type  of  the  ordinary 
epididymitis  and  are  not  followed  by  atrophy. 

When,  after  a  comparatively  slight  trauma,  testicular  lesions  persist 
and  progress,  it  may  be  suspected  that  there  was  a  latent  tuberculosis, 
syphilis,  or  malignant  infiltration  before  the  injury. 

Luxation  of  the  testicle  may  be  due  to  trauma  or  muscular  action. 
The  usual  cause  is  sudden,  violent  contraction  of  the  cremaster  muscle, 
which  may  fix  the  testis  in  the  groin  external  to  the  ring  from  tonic 
spasm,  may  lodge  it  in  the  inguinal  canal,  or  may  draw  it  within  the 
abdominal  cavity.  The  testis  is  usually  found  within  the  inguinal 
canal  acutely  inflamed,  because  of  the  violence  to  which  it  has  been 
subjected,  and  exhibiting  tenderness  and  tumor  sufficiently  characteristic. 

Urethral  epididymitis  is  an  expression  of  inflammation  carried  along 
the  vas.  It  is  a  common  sequel  of  gonorrheal  and  of  instrumental 
urethritis;  it  occasionally  complicates  gouty  urethritis. 

The  diagnostic  symptoms  are  a  tender  edematous  swelling  at  the  back 
of  the  testis  as  large  as  this  gland  or  even  larger;  tenderness  and  swelling 
along  the  cord;  severe  pain  in  the  testis  and  back  aggravated  by  standing, 
walking,  or  straining;  shortly  an  effusion  into  the  tunica  vaginalis  con- 
stituting an  acute  hydrocele,  and  simulating  a  swollen  testicle;  often 
tender,  swollen  ampulla  and  seminal  vesicle  detected  on  rectal  exami- 
nation; fever  and  mental  depression.  The  urethral  origin  of  the  infec- 
tion is  established  by  the  presence  of  a  purulent  discharge  from  the 
meatus,  or  of  pus  of  posturethral  origin  in  the  urine  (see  p.  675). 

Tympany  and  vomiting,  and  tenderness,  pain,  and  rigidity  in  the 
right  iliac  fossa  may  be  prodromal  symptoms  due  to  peritoneal  extension 
from  the  inflamed  seminal  vesicle.  The  symptoms  reach  their  height 
in  about  five  days. 

In  some  cases  the  onset  is  insidious,  the  progress  non-crippling, 
provided  proper  support  be  worn,  and  the  sole  symptom,  aside  from 
urethral  pus,  an  enlarged  epididymis,  which  may  almost  completely 
surround  the  testis. 


654  THE  GENITO-URINARY  ORGANS 

Gonorrheal  epididymitis  rarely  suppurates,  and,  as  a  rule,  undergoes 
almost  complete  resolution,  leaving  a  permanent  induration  in  the  tail 
of  the  epididymis,  which,  exceptionally,  completely  and  permanently 
blocks  the  channel  against  the  passage  of  spermatozoa. 

Urethral  epididymitis  of  catheter  origin  (mixed  infection)  often  gives 
rise  to  destructive  abscess  formation,  characterized  by  softening,  the 
discharge  of  pus,  and  at  times  the  formation  of  multiple  sinuses  burrowing 
through  enormously  thickened  scrotal  tissues.  Such  abscesses  may 
terminate  in  complete  sloughing  of  both  the  epididymis  and  the  testis. 

As  a  result  of  abscess,  fungus  may  develop  characterized  by  exuberant 
granulations  usually  from  the  scrotal  tissue.  If  from  the  testicle  or 
epididymis,  the  discharge  will  contain  the  glandular  or  tubular  structure 
of  these  organs. 

Tuberculous  epididymitis  exceptionally  begins  precisely  as  does  an 
acute  gonorrheal  epididymitis;  the  diagnosis  must  at  first  be  based 
upon  the  absence  of  gonococci  or  catheter  infection  as  causative  agents, 
and  the  usual  association  of  tuberculous  lesions  elsewhere,  particularly 
in  the  genito-urinary  tract.  The  subsequent  course  of  the  affection 
will  later  suggest  the  diagnosis. 

Acute  orchi-epididymitis  may  occur  in  the  course  of  mumps,  malaria, 
tonsillitis,  typhoid,  scarlatina,  influenza,  and  gout.  The  symptoms 
are  those  of  urethral  epididymitis,  except  that  there  is  no  urethral 
infection,  but  slight  hydrocele,  and  the  testicle  is  the  structure  most 
seriously  affected;  hence  it  forms  the  bulk  of  the  swelling,  maintaining, 
however,  its  characteristic  form. 

This  inflammation  is  sometimes  the  sole  expression  of  mumps. 
Diagnosis  will  then  be  based  upon  the  absence  of  other  causes  of  inflam- 
mation and  the  history  of  exposure  to  mumps.  Mumps  orchitis  is 
often  followed  by  atrophy. 

Typhoid  and  tonsillitis  orchitis  is  like  that  secondary  to  mumps. 

Malarial  orchitis  is  characterized  by  regular  recurrence  of  attacks 
independent  of  other  reason  and  the  finding  of  the  malarial  organism. 

Gouty  orchitis  is  recurrent  and  alternates  with  other  gouty  symptoms, 
disappearing  when  arthritis  develops  and  reappearing  as  the  latter  sub- 
sides.    It  occurs  in  sudden  seizures. 

Swellings  of  the  Testicles  and  Epididymis  without  Symptoms  of 
Acute  Inflammation. — ^The  fluid  swellings  are  hydrocele,  cysts  of  the 
epididymis  or  testis,  and  hematocele,  the  latter  often  giving  the  impres- 
sion of  a  solid  tumor. 

The  solid  swellings  are  tuberculous,  syphilitic,  or  malignant.  Excep- 
tionally benign  tumors  develop. 

Hydrocele  .^ — Hydrocele,  the  commonest  scrotal  tumor,  is  essentially 
an  affection  of  infancy  and  old  age.  It  is  characterized  in  the  adult 
by  the  development  of  a  slowly  growing  (years),  painless,  smooth,  tense, 
heavy,  elastic,  fluctuating,  pyriform  tumor,  over  which  the  skin  is  freely 
movable.  The  cord  is  not  enlarged.  Fluctuation  is  best  elicited  by 
holding  the  tumor  firmly  in  one  hand  and  lightly  percussing  with  a 
finger  of  the  other. 


THE  TESTICLE  AND  EPIDIDYMIS 


655 


Translucency  is  the  most  convincing  single  sign  aside  from  aspira- 
tion. This  test  is  best  conducted  in  a  dark  room  and  by  means  of 
a  small  electric  light  placed  sufficiently  deep  within  a  small  metal  cup 
to  allow  the  opening  of  the  latter  to  be  pressed  closely  against  the 
scrotal  skin,  thus  shutting  in  all  rays  except  those  which  pass  through 
the  scrotum.  In  the  absence  of  an  electric  light,  translucency  may  be 
elicited  by  a  candle  held  close  to  the  tumor,  over  which  the  scrotal 
skin  has  been  tensely  stretched.     The  surgeon  inspects  from  the  side 

Fig.  433 


Tense  hydrocele.     Showing  projection  into  groin.     Dull  on  percussion. 
Fluctuation  present.     Translucent. 


Irreducible.     No  impulse. 


opposite  the  candle,  shielding  his  eyes  from  the  direct  rays  of  the  light 
by  the  open  hand  placed  with  its  ulnar  border  on  the  convexity  of  the 
tense  tumor.  This  inspection  can  be  made  through  a  tube — a  cylin- 
drical proctoscope  answers  well — or  a  thick  paper  rolled  into  a  cylinder 
and  so  held  to  the  examining  eye  that  light  is  excluded  except  that 
which  passes  through  the  hydrocele. 

To  be  diagnostic,  the  translucency  should  be  clear  and  unmistakable, 
since  lipoma  may  give  this  symptom  faintly. 


656  THE  GEN ITO-U BINARY  ORGANS 

The  final  diagnosis  is  made  by  the  aspiration  of  a  fluid  which  may  be 
clear,  or  turbid  from  admixture  with  cholesterin,  blood,  or  spermatozoa 
(encysted  hydrocele). 

The  position  of  the  testicle  in  regard  to  the  fluid  can  usually  be  deter- 
mined by  digital  pressure,  the  latter  eliciting  the  typical  tenderness. 
Moreover,  where  the  testicle  lies  there  will  be  diminished  translucency. 
When  fluctuation,  translucency,  and  testicular  sensation  cannot  be 
elicited,  diagnosis  should  be  made  by  incision. 

Hydrocele  of  the  tunica  vaginalis  may  be  bilocular  or  multilocular, 
and  may  occur  in  the  acute  form,  in  which  case  it  is  usually  secondary 
to  epididymitis. 

Chronic  hydrocele  usually  distends  the  closed  sac  of  the  tunica 
vaginalis  alone;  it  may  also  involve  its  funicular  process  (infantile 
hydrocele),  or  if  a  communication  between  that  and  the  peritoneum 
still  exists,  it  may  communicate  with  the  general  abdominal  cavity 
(congenital  hydrocele).  If  the  testis  be  in  the  inguinal  region,  the 
hydrocele  will,  of  course,  develop  here. 

A  huge  hydrocele  extending  up  into  the  inguinal  canal  may  be  diffi- 
cult to  distinguish  from  irreducible  omental  hernia,  or  the  latter  may 
be  a  complicating  factor.  The  history  of  the  case,  when  this  can  be 
elicited,  is  conclusive,  hernia  beginning  from  above  and  the  hydro- 
cele from  below.  Moreover,  hernia  is  usually,  in  its  early  develop- 
ment, an  intermittent  tumor  dependent  upon  abdominal  strain  for  its 
recurrence. 

The  distinction  between  hydrocele  and  hernia  of  the  undescended 
testis  will  be  based  upon  the  distinct  fluctuation  of  hydrocele,  its  persist- 
ence, and  the  absence  of  the  usual  attributes  of  hernia.  At  times  the 
differential  diagnosis  is  not  possible.  This  is  particularly  the  case  in 
the  congenital  form  of  hydrocele.  The  inguinal  hydrocele  is  often 
bilocular. 

Cysts  of  the  Epididymis  and  Testicle. — These  cysts  usually  grow 
from  the  head  of  the  epididymis,  forming  an  elastic,  rounded,  or  multi- 
locular tumor  just  above  the  testicle,  of  varying  size  but  rarely  larger 
than  the  gland  itself,  giving  rise  to  no  symptoms,  and  stationary  or 
exceedingly  slow  in  growth.  Such  cysts  usually  contain  spermatozoa, 
hence  the  translucence  is  not  as  marked  as  in  the  case  of  hydrocele. 
Diagnosis  is  based  upon  the  absolute  indolence  of  the  affection  and, 
if  tuberculosis  be  suspected,  exploratory  incision.  Because  of  the 
tension  of  the  fluid  in  these  cysts  they  are  often  mistaken  for  solid 
tumors. 

Encysted  hydrocele  of  the  testicle  arises  from  the  substance  of  the 
latter  and  forms  a  tense,  circumscribed,  elastic  tumor  covered  by  the 
visceral  layer  of  the  tunica  vaginalis.  It  usually  contains  a  fluid  turbid 
with  spermatozoa. 

Loose  bodies  in  the  tunica  vaginalis  are  usually  discovered  accident- 
ally. They  present  a  smooth  surface,  move  freely,  and  are  accompanied 
by  a  slight  degree  of  hydrocele.  The  trouble  caused  by  these  bodies 
is  usually  psychic  rather  than  physical. 


THE  TESTICLE  AND  EPIDIDYMIS  657 

Hematocele. — Hematocele  may  be  acute  or  chronic  in  its  develop- 
ment. In  the  former  case,  incident  to  trauma  or  violent  muscular 
strain,  it  forms  a  fluctuating  tumor,  non-translucent,  entirely  enveloping 
the  testis,  and  corresponding  to  its  shape.  There  is  usually  an  accom- 
panying ecchymosis  of  the  scrotum. 

There  may  be  complete  resolution,  or  the  condition  may  degenerate 
into  a  chronic  one. 

Chronic  hematocele  is  characterized  by  a  thickening  of  the  vaginal 
tunic,  often  of  such  degree  as  to  simulate  a  solid  tumor.  The  testicle 
proper  commonly  lies  in  the  posterior  wall  of  this  thickened  mass,  and 
ultimately  undergoes  pressure  atrophy.  It  is  an  affection  of  early  old 
age,  exhibits  a  smooth,  rounded,  unbossed  tumor,  beginning  with  a  strain, 
trauma,  or  preexisting  hydrocele,  growing  slowly  (years),  and  with 
periods  of  acute  exacerbation,  attended  with  moderate  inflammatory 
symptoms,  due  to  fresh  hemorrhages  into  the  sac. 

The  diagnosis,  unless  the  time  limit  (years)  excludes  malignant  growth, 
should  be  made  by  incision,  since  aspiration  is  not  sufficiently  conclusive. 

Intratesticular  hematocele  would  be  suggested  by  severe,  crippling, 
persistent  (weeks)  testicular  pain  following  trauma. 

Tuberculosis. — Tuberculosis  attacks  the  epididymis  by  preference, 
usually  its  head,  forming  one  or  more  nodules  which  soften  and  dis- 
charge (months  or  years).  Exceptionally  the  outbreak  is  acute,  simu- 
lating the  gonorrheal  form  of  epididymitis,  followed  by  persistence  of 
infiltrations  and  nodulations,  involving  not  merely  the  tail  of  the  epididy- 
mis, but  the  whole  of  its  substance. 

The  usual  form  is  characterized  by  the  painless  development  of  one 
or  more  nodules,  usually  discovered  accidentally.  Sometimes  accom- 
panied by  a  slight  sense  of  weight  and  dragging,  which  leads  the  patient 
to  make  an  examination.  There  is  very  commonly  a  preceding  and 
associated  slight  mucopurulent  urethral  discharge,  together  with  evi- 
dences of  tuberculosis  elsewhere,  particularly  in  the  genito-urinary 
tract. 

The  characteristic  features  of  the  affection  are  the  inadequacy  of  a 
cause  other  than  tuberculosis  to  produce  usually  in  young  adults  an 
indolent,  painless,  nodular,  often  bilateral  swelling  of  the  epididymis, 
which  ultimately  tends  to  an  almost  painless  breaking  down,  leaving 
one  or  more  sinuses  which  discharge  cheesy  pus.  Exceptionally,  the 
tuberculous  foci  become  permanently  encysted.  The  cord  is  usually 
thickened  and  finely  nodular. 

The  tuberculin  test,  microscopic  examination  of  the  wound  discharge, 
injection  of  accompanying  hydrocele  fluid  into  guinea-pigs,  are  all  means 
of  diagnostic  corroboration. 

The  affection  is  usually  bilateral,  nor  will  prompt  removal  of  the 
affected  testis  prevent  a  secondary  involvement  of  the  remaining  appar- 
ently healthy  one. 

In  infants,  tuberculosis  affects  by  preference  the  body  of  the  testis; 
it  may  have  a  subacute  onset,  appearing  first  as  a  hydrocele  or  as  a  tender, 
swollen  testis,  with  reddening  of  the  overlying  scrotum.  Persistence  of 
42 


658  THE  GENITO-URINARY  ORGANS 

inflammatory  symptoms  and  early  softening  and  sinus  formation  are 
characteristic  features.  If  syphilis  be  excluded  as  a  cause  of  the 
nodular  infiltration,  distinction  from  neoplasm  should  be  made  by 
operation. 

Cysts  of  the  epididymis  are  more  elastic  and  sharply  rounded  than 
tuberculous  infiltrates,  the  body  and  tail  of  the  epididymis  remain  per- 
fectly normal  to  palpation,  and  there  is  no  .tendency  to  sinus  formation. 

Gumma  usually  involves  the  testicle  first,  and  is  characterized  by  a 
history  of  syphilis,  the  presence  or  traces  of  other  specific  lesions,  and 
absence  of  tuberculous  stigmata. 

Syphilis  of  the  Testicle. — Syphilis  of  the  testicle  is  usually  expressed 
in  the  form  of  sometimes  symmetrical,  usually  bosselated  or  ridged, 
painless,  densely  hard,  often  bilateral  enlargement,  associated  with  a 
moderate  degree  of  hydrocele;  persisting  for  months  with  slow  increment. 
The  cord  is  not  enlarged.  On  reaching  the  size  of  a  fist,  the  infiltrate 
undergoes  resolution,  leaving  an  atrophied  and  distorted  testis,  or 
breaks  down,  discharging  gummy  pus.  Exceptionally  the  onset  is 
characterized  by  the  symptoms  of  a  mild  or  acute  orchitis. 

The  diagnosis  is  based  upon  the  history  and  associated  symptoms  of 
syphilis,  the  absence  of  inflammatory  phenomena,  the  at  first  rapid 
(weeks)  then  slow  (months)  progress,  and  the  therapeutic  test.  When 
the  onset  is  subacute,  the  diagnosis  must  be  by  exclusion,  and  must 
depend  upon  the  history  of  the  case  and  the  therapeutic  test. 

From  tuberculosis  the  distinction  may  be  made,  in  the  adult,  by  the 
fact  that  the  latter  nearly  always  attacks  the  epididymis  first  and  exhibits 
lesions  elsewhere. 

From  malignant  infiltration,  a  timely  diagnosis  must  depend  upon  the 
history  of  the  case,  a  therapeutic  test,  and  incision  and  microscopic 
examination. 

Malignant  Tumor  of  the  Testicle. — Malignant  tumor  of  the  testicle, 
usually  in  the  form  of  soft  carcinoma,  at  times  mixed  sarcoma,  and 
commonly  enough  beginning  with  trauma  or  inflammation,  usually 
develops  before  middle  age;  occasionally  in  children.  It  is  char- 
acterized by  a  comparatively  painless,  usually  symmetrical,  rapid 
(weeks  or  months)  enlargement  of  the  testis.  The  postperitoneal 
glands  are  quickly  invaded. 

The  diagnosis  based  upon  the  presence  of  a  rapidly  increasing 
enlargement  in  the  absence  of  adequate  cause  other  than  malignancy 
should  be  made  by  incision  and  microscopic  examination,  since,  when 
the  features  of  the  case  are  such  as  to  be  entirely  characteristic,  i.  e., 
large  tumor,  dilated  veins,  and  involved  lymphatics,  operative  treatment 
is  futile. 

Neuralgia  of  the  Testicle  .^ — Neuralgia  of  the  testicle,  by  which  is  meant 
intense,  persistently  recurring  pain,  without  demonstrable  lesion,  is 
sufficiently  often  dependent  upon  either  varicocele,  encysted  hematocele, 
or  a  beginning  tuberculous  or  malignant  infiltration  to  justify  exploratory 
operation. 


THE  SPERMATIC  CORD  659 


THE  SPERMATIC  CORD. 

The  vas  may  be  absent  on  one  or  both  sides  without  other  obvious 
defect. 

Trauma  or  muscular  strain  may  cause  hemorrhage  characterized 
by  the  rapid  formation  of  a  doughy,  sausage-shaped  tumor,  occupying 
the  position  of  the  cord,  simulating  hernia  of  sudden  formation. 

Acute  funiculitis  is  a  common  accompaniment  of  urethral  epididy- 
mitis and  is  characterized  by  pain,  tenderness,  and  thickening. 

In  the  course  of  tuberculous  epididymitis  the  vas  is  very  commonly 
finely  nodular  and  infiltrated,  and  the  v^hole  cord  is  thickened. 

In  malignant  infiltration  the  cord  is  often  enormously  thickened. 

Varicocele  is  the  commonest  affection  of  the  cord.  It  is  characterized 
by  a  soft  mass  of  thickened,  dilated,  and  tortuous  veins  occupying 
the  position  of  the  cord,  not  only  palpable,  but  often  obvious  to  inspec- 
tion. In  its  extreme  development  it  gives  impulse  on  coughing,  and 
partially  disappears  on  taking  the  recumbent  posture.  Exceptionally 
it  is  attended  with  atrophy  of  the  testis.  It  occasions  psychic  rather 
than  physical  disturbance,  but  occasionally  neuralgic  pain  and  sexual 
neurasthenia  are  distinctly  referable  to  it. 

It  is  an  affection  of  youth,  appearing  after  maturity  without  obvious 
cause.  It  is  suggestive  of  venous  obstruction  of  postperitoneal  origin, 
particularly  of  hypernephroma. 

The  distinction  from  omental  hernia  is  made  from  the  peculiar  worm- 
like feeling  characteristic  of  the  dilated,  tortuous,  and  often  thickened 
veins,  the  fact  that  the  tumor  began  in  the  lower  part  of  the  scrotum, 
that  it  can  be  partly  reduced  by  the  recumbent  posture,  and  pressure 
over  the  internal  or  the  external  ring  on  resumption  of  the  erect  position 
does  not  prevent  its  slowly  growing  large  from  below  upward. 

From  discrete  lipoma,  diagnosis  will  be  made  with  difSculty.  There 
is  no  alteration  in  the  size  of  lipoma  dependent  upon  position  or  intra- 
abdominal strain.     Moreover,  this  affection  is  extremely  rare. 

Hydrocele  of  the  cord,  usually  seen  in  infants,  forms  a  soft,  fluctuating, 
translucent  tumor  occupying  the  position  of  the  cord;  beneath  it  the 
testicle  can  be  felt.  It  may  be  acute  in  development,  in  which  case  it 
is  rather  an  edema  than  an  effusion  into  a  patulous  funicular  portion 
of  the  vaginal  tunic. 

The  encysted  hydrocele  of  the  cord  is  (patulous,  funicular  portion  of 
the  vaginal  tunic)  insidious  in  development,  chronic  in  course,  unilocular 
or  multilocular,  common  in  children,  but  noted  in  the  adult,  and  often 
complicated  by  hernia.  It  appears  as  a  smooth,  tense,  ovoid  swelling 
in  some  portion  of  the  spermatic  cord.  Beneath  this  the  testis  can 
usually  be  recognized.  It  is  usually  mistaken  for  hernia,  and  can  often 
be  pressed  back  into  the  inguinal  canal,  but  cannot  be  really  reduced. 
Moreover,  translucency  is  present,  nor  are  the  characteristic  features 
of  hernia  to  be  found  unless  this  condition  be  associated  with  congenital 
hydrocele. 


660  THE  GENITO-URINARY  ORGANS 

Lipoma  of  the  cord  (rare)  forms  a  slow  (years),  soft,  painless,  ill-defined 
growth  in  the  course  of  the  cord,  between  the  structures  of  which  it  may 
intimately  infiltrate.  The  tumor  grows  from  below  upward.  When 
it  has  traversed  the  inguinal  canal,  the  distinction  between  it  and  irre- 
ducible omental  hernia  can  be  made  only  on  the  history  of  the  case 
and  examination  through  an  incision. 


THE  SEMINAL  VESICLES. 

The  seminal  vesicles  form  two  lobulated  pouches  inclosed  in  dense 
fascia,  passing  from  the  walls  of  the  bladder  to  the  posterior  border  of 
the  prostate.  They  vary  greatly  in  size  within  normal  limits,  averaging 
about  two  and  one-half  inches  in  length  and  one-half  inch  in  breadth, 
and  terminating  in  a  duct  which  unites  with  the  vas  just  before  the  latter 
enters  the  substance  of  the  prostate.  The  upper  extremities  of  the 
seminal  vesicles  are  in  close  relation  to  the  peritoneum  of  the  rectovesical 
pouch.     The  function  of  the  vesicles  is  entirely  secretory. 

Malformations, — One  or  both  seminal  vesicles  may  be  absent,  usually 
associated  with  other  malformations  of  the  sexual  organs.  They  may 
be  fused,  multiple,  or  atrophic.  Or  they  may  communicate  with  the 
ureter. 

The  ejaculatory  duct,  formed  by  the  fusion  of  the  vas  and  duct  of  the 
seminal  vesicle,  normally  pierces  the  prostatic  isthmus,  opening  at  the  sides 
of  the  prostatic  utricle.  This  duct  may  be  absent,  partially  wanting,  or 
fused,  or  it  may  be  continued  forward,  forming  a  canal  which  opens  at 
some  point  on  the  glans  penis,  suggesting  a  double  urethra. 

Acute  Vesiculitis. — ^Acute  vesiculitis,  or  spermatocystitis,  is  due  to 
extension  of  inflammation,  usually  gonococcal,  from  the  posterior  urethra 
into  the  seminal  vesicle.  The  symptoms  are  those  of  aggravated  posterior 
urethritis  (see  p.  667),  except  that  the  pain '  radiations  are  character- 
istic, being  referred  not  only  to  the  perineum,  anus,  and  hypogastric 
region,  but  also  to  the  hip-joint  of  the  affected  side  and  the  outer  surface 
of  the  leg.  Frequent  erection  and  painful  nocturnal  emissions  of  blood- 
stained purulent  semen  are  common. 

Exceptionally  seminal  vesiculitis  is  ushered  in  with  the  vomiting, 
tympany,  and  symptoms  of  acute  local  peritonitis,  even  including 
rigidity  and  tenderness  on  deep  pressure  in  the  iliac  fossa  corresponding 
to  the  seminal  vesicle  involved.  If  this  be  the  right  one,  a  diagnostic 
error  may  readily  be  made. 

The  diagnosis  is  based  upon  rectal  examination.  If  practicable  the 
patient  should  have  a  fairly  full  bladder  and  should  lean  forward  sup- 
porting himself  by  the  hands  placed  upon  a  table  or  chair,  with  the  legs 
slightly  separated.  Lying  above  the  prostate  and  extending  obliquely 
upward  and  outward  from  it  will  be  found  a  tender  mass,  usually  about 
the  size  of  the  thumb.  When  both  vesicles  are  inflamed  there  is  felt 
above  the  prostate  a  hot,  broad,  tender  infiltration  suggesting  on  palpa- 
tion an  enormously  enlarged  prostate.     This  is  lacking  in  the  density 


THE  SEMINAL  VESICLES  661 

of  true  prostatic  swelling  and  on  careful  palpation  the  prostate  can  be 
distinctly  outlined  below  the  mass. 

A  distinction  between  seminal  vesiculitis  and  inflammation  of  the 
ampulla  of  the  vas  cannot  be  made. 

Chronic  Vesiculitis. — Chronic  vesiculitis  is  the  usual  termination  of  an 
acute  attack.  It  may,  however,  develop  with  symptoms  so  slight  as  to 
attract  little  attention.  It  is  practically  always  complicated  by  posterior 
urethritis  and  is  a  common  cause  for  the  continuance  of  this  condition. 

It  is  characterized  by  sexual  neurasthenia,  slight  anemia  of  the  toxic 
type,  usually  a  persistent  gleet,  and  recurring  attacks  of  subacute  or 
acute  urethritis  from  inadequate  cause.  Monoarticular  or  polyarticular 
rheumatism  is  a  not  infrequent  expression  of  systemic  infection,  even  in 
the  absence  of  marked  local  symptoms.  Pus  in  the  urine  is  constant; 
anterior  discharge  appears  during  the  subacute  or  acute  attacks. 

These  symptoms  do  not  differ  from  those  of  a  chronic  posterior  ure- 
thritis kept  up  by  persistent  infection  of  glands  or  follicles,  hence  the 
diagnosis  can  be  made  only  by  rectal  examination,  which  demonstrates 
a  swollen,  usually  softly  bossed,  sometimes  nodular  vesicle,  from  which 
can  be  expressed  pus  and  blood.  For  the  collection  of  this  the  patient 
passes  a  small  part  of  his  urine.  The  prostate  is  then  massaged,  and 
he  urinates  again,  but  does  not  empty  the  bladder.  The  vesicles  are 
next  massaged  and  the  urine  remaining  in  the  bladder  is  passed.  In 
this  last  portion  will  be  found  the  pus  expressed  from  the  vasal  ampullae 
and  the  seminal  vesicles. 

Tuberculous  Vesiculitis. — ^Tuberculous  vesiculitis  is  usually  associated 
with  other  tuberculous  lesions,  particularly  with  nephritis,  cystitis,  and 
epididymitis. 

If  the  bladder  be  free  from  invasion,  the  symptoms  are  slight  or  wanting. 
When  present,  they  are  those  of  chronic  posterior  urethritis.  Sexual 
erythism,  bloody  semen,  and  pain  during  and  after  ejaculation  are 
frequently  noted. 

The  diagnosis  is  based  upon  the  finding  by  rectal  examination  of  an 
irregular,  nodular,  non-sensitive  growth  occupying  the  position  of  the 
seminal  vesicle;  not  explainable  from  a  history  of  a  preceding  gono- 
coccal or  infectious  urethritis,  slowly  and  obstinately  progressive,  made 
worse  by  ordinary  treatment  applicable  to  chronic  seminal  vesiculitis, 
and  associated  with  the  evidences  of  tuberculous  invasion  elsewhere. 

Absolute  diagnosis  is  made  by  finding  tubercle  bacilli  in  the  urine  or  in 
the  expressed  discharge. 

Cysts  of  the  seminal  vesicles,  due  to  obstruction  of  the  ejaculatory 
ducts,  are  characterized  by  pressure  symptoms.  Diagnosis  is  based  upon 
rectal  palpation  and  the  position  of  the  cysts.  These  can  be  differen- 
tiated from  dermoid  cysts  similarly  placed  only  by  operation.  Concre- 
tions sometimes  form  in  the  seminal  vesicle  and  become  of  surgical 
interest  only  when  they  produce  blocking  of  the  ejaculatory  duct. 

Painful  emissions  and  the  symptoms  of  chronic  vesiculitis  suggest  a 
rectal  examination  which  shows  the  presence  of  one  or  more  bodies  of 
stone-like  hardness  lying  between  the  bladder  wall  and  the  rectum. 


662  THE  GENITO-URINARY  ORGANS 

Malignant  infiltration  of  the  seminal  vesicle  is  always  secondary  to  that 
of  the  prostate.  It  is  characterized  by  a  stony  induration  confluent  with 
an  equally  dense  prostate. 

THE  PROSTATE. 

The  average  normal  adult  prostate  is  about  one  and  one-half  inches 
wide,  one  and  one-quarter  inches  long,  and  three-quarters  of  an  inch 
thick,  weighing  about  five  drams;  it  is  made  up  of  glandular  tissue  and 
smooth  muscular  fibers.  In  shape  it  resembles  somewhat  a  chestnut, 
but  is  subject  to  marked  variations  in  both  shape  and  size.  On  rectal 
examination  it  is  distinctly  bilobed,  the  two  halves  being  connected  by 
an  isthmus  which  sometimes  forms  a  distinct  projection  called  the  third 
lobe.  This  isthmus  lies  just  below  the  vesical  orifice  of  the  urethra 
and  above  and  behind  the  ejaculatory  ducts,  discharging  its  secretion 
into  that  portion  of  the  urethra  which  lies  nearest  the  bladder. 

The  prostate  is  situated  behind  and  slightly  below  the  symphysis 
pubis,  lying  between  the  posterior  layer  of  the  triangular  ligament  and 
the  neck  of  the  bladder,  which  is  surrounded  by  its  base.  It  is 
separated  from  the  rectum  by  a  thin,  rectovesical  fascia  and  by  the 
prostatic  sheath.  The  latter  completely  invests  the  gland,  forming  a 
tough,  connective-tissue  covering  in  which  are  found  the  large  veins 
of  the  prostatic  plexus. 

The  symptoms  common  to  surgical  affections  of  the  prostate  are  en- 
largement or  deformity,  detected  by  rectal,  urethral,  or  cystoscopic 
examination,  interference  with  the  function  of  micturition,  and  pain. 

Inflammatory  Affections  of  the  Prostate.  — Acute  Prostatitis  is  usually 
due  to  extension  of  gonorrheal  or  catheter  urethritis.  The  symptoms 
are  pus  in  the  urine  from  the  originating  urethral  infection,  a  feeling 
of  weight  in  the  perineum,  pain  greatly  increased  by  urination  and  defe- 
cation, frequency  in  urination,  possible  difficulty  in  starting  the  stream, 
failure  to  experience  complete  relief  after  the  bladder  is  apparently 
emptied,  and  either  circumscribed  or  diffuse  prostatic  tenderness  and 
swelling  detected  by  rectal  examination. 

If  inflammation  goes  on  to  abscess  formation  there  are  the  local  and 
constitutional  signs  of  this  affection,  i.  e.,  increase  of  pain  which  becomes 
throbbing,  burning,  and  almost  unendurable  in  its  intensity,  added 
difficulty  in  urination,  and  constitutional  symptoms  of  deep  pus.  Fluc- 
tuation may  be  detected  by  rectal  palpation. 

Complete  retention  is  common,  and  because  of  associated  pelvic 
congestion,  hemorrhoids  are  a  frequent  complication. 

The  symptoms  are  so  like  those  of  a  posterior  urethritis  that  diagnosis 
must  be  based  upon  rectal  palpation  which  reveals  a  hot,  tender  tumor 
occupying  the  position  of  the  prostate. 

If  the  abscess  be  confined  to  one  or  more  prostatic  follicles,  these 
commonly  open  into  the  urethra,  giving  prompt  relief,  with  increase  of 
the  discharge,  often  with  some  blood  admixture.  This  is  the  usual  ter- 
mination.    If  the  abscess  has  burst  its  glandular  environment,  involving 


THE  PROSTATE  663 

a  part  or  the  whole  of  the  substance  of  the  prostate,  rupture  may  still 
take  place  into  the  urethra  or  rectum,  or  the  pus  may  burrow  through 
the  pelvis,  forming  multiple  fistulse  opening  in  regions  remote  from  the 
prostate,  and  exceedingly  difficult  to  heal. 

Exceptionally  a  huge  pelvic  abscess  of  prostatic  origin  may  develop, 
with  almost  no  symptoms,  the  diagnosis  being  formulated  on  symptoms 
of  profound  sepsis  and  the  findings  by  rectal  examination. 

Chronic  prostatitis  is  predisposed  to  by  congestion,  such  as  that  incident 
to  prolonged  ungratified  sexual  excitement,  excessive  coitus,  masturba- 
tion, habitual  constipation,  urethral  stricture,  or  irritating  conditions  of 
the  urine.     It  is  directly  caused  by  infection. 

It  is  characterized  by  increased  frequency  of  urination  and  often 
burning  pain  during  and  after  the  act,  deep  perineal  pains  radiating 
to  the  rectum  and  down  the  thighs,  made  worse  by  exertion,  slight 
perineal  tenderness,  induration,  possibly  nodulation,  of  the  prostate,  pus 
in  the  urine  at  times.  There  are  frequently  intercurrent  subacute  attacks 
of  inflammation,  the  general  symptoms  of  mild  septic  absorption,  such 
as  headache,  backache,  myalgia,  and  indigestion,  sexual  neurasthenia, 
and  a  slight  toxic  anemia.  On  rectal  examination  the  prostate  may 
be  unduly  sensitive  at  some  portion  of  its  surface,  this  tenderness  being 
nearly  always  localized.  The  urine  passed  after  milking  the  prostate 
contains  a  considerable  quantity  of  pus. 

Chronic  prostatitis  may  persist  for  years  with  no  symptoms  other  than 
pus  in  the  urine,  detected  only  by  careful  examination. 

Calculi  of  the  Prostate. — Prostatic  calculi,  usually  due  to  deposits  of 
lime  salts  in  suppurating  prostatic  follicles  or  abscess  cavities,  excep- 
tionally to  concretions  formed  about  the  corpora  amylacea,  are  found 
in  the  region  of  the  verumontanum.  They  may  give  no  symptoms. 
Usually  they  are  characterized  by  those  of  posterior  urethritis. 

The  diagnosis  is  made  by  rectal  palpation  and  urethral  examination. 
If  the  calculi  are  large,  they  can  usually  be  felt  by  the  finger  introduced 
into  the  rectum.  They  may  also  be  detected  by  the  passage  of  metal 
instruments,  which  will  give  a  click,  or  by  the  introduction  of  the 
urethroscope.     The  a:-rays  give  a  characteristic  shadow. 

The  distinction  from  vesical  calculi  will  be  made  by  the  fixed  position 
of  the  stones,  determined  by  passing  a  metal  instrument  with  the  finger 
in  the  rectum. 

Enlargement  of  the  Prostate  .^ — ^This  is  an  affection  of  middle  and  old 
age.  It  is  characterized  solely  by  obstructive  symptoms,  to  which,  when 
infection  occurs,  are  added  those  of  inflammation. 

The  typical  obstructive  symptoms  are  increased  frequency  of  micturi- 
tion most  marked  during  the  night  or  early  in  the  morning,  delay  in 
starting  the  stream,  loss  of  force,  interruptions  during  the  passage  of  the 
stream,  and  dribbling  at  the  completion  of  the  act.  Later,  when  the 
bladder  becomes  distended,  there  may  be  incontinence  due  to  the  over- 
flow of  urine  from  an  atonic  and  greatly  dilated  bladder. 

There  is  usually  polyuria  due  to  back  pressure  and  slight  albuminuria 
with  hyaline  casts. 


664  THE  GENITO-URINARY  ORGANS 

When  inflammation  is  added  to  obstruction,  urgency,  pain,  and  pyuria 
further  compHcate  the  picture. 

The  diagnosis  is  based  upon  rectal  palpation,  measurement  of  urethral 
length,  cystoscopic  or  instrumental  examination  of  the  posterior  urethra 
and  its  vesical  orifice,  and  the  detection  of  residual  urine. 

Hypersecretion  of  urine  may  occasion  frequency,  but  without  the  other 
symptoms  of  enlarged  prostate. 

Sclerosis  and  contracture  of  the  internal  vesical  sphincter  will  produce 
all  the  symptoms  of  prostatic  hypertrophy,  with  the  exception  of  enlarge- 
ment felt  through  the  rectum  and  increased  urethral  length. 

Stricture  will  produce  all  the  symptoms,  but  the  history  of  a  pre- 
ceding trauma  or  inflammation  (usually  years  before)  and  the  passage 
of  a  urethral  instrument  will  clear  the  diagnosis.  Moreover,  the  pros- 
tate is  not  found  unduly  enlarged  on  rectal  examination. 

To  determine  the  extent  to  which  the  urethra  is  lengthened,  a  soft 
elbowed  catheter  is  employed.  This  is  first  passed  down  to  the  membran- 
ous urethra.  The  anterior  urethra  is  then  thoroughly  flushed  out  with 
a  mild  antiseptic  solution.  The  catheter  is  pushed  on  until  the  urine 
begins  to  flow.  A  point  on  the  shaft  corresponding  to  the  meatus  is 
marked  and  after  the  bladder  has  been  emptied  the  catheter  is  withdrawn 
and  the  distance  from  this  mark  to  the  eye  of  the  instrument  is  taken. 
This  measurement  represents  roughly  the  urethral  length.  If  it  be 
more  than  eight  to  eight  and  one-half  inches,  this  suggests  prostatic 
enlargement. 

The  thickness  of  the  isthmus,  the  so-called  median  lobe,  can  be 
determined  by  introducing  a  sound  into  the  bladder  and  palpating 
on  this  through  the  rectum.  Moreover,  by  means  of  this  sound,  if  it 
be  provided  with  a  sharp  curve  such  as  is  common  in  stone  sounds, 
the  size,  and  the  direction  of  intravesical  projections  can  be  roughly 
determined.  This  can  be  more  accurately  done  by  the  use  of  the  cysto- 
scope. 

The  amount  of  residual  urine  is  estimated  by  directing  the  patient 
to  empty  the  bladder,  then  introducing  the  soft  catheter  and  drawing 
off  all  that  remains.  Normally  not  more  than  a  few  drops  of  urine 
should  be  drawn. 

Unusually  severe  pain  and  tenesmus,  especially  if  associated  with 
blood  and  pus  in  the  urine,  should  suggest  vesical  stone  as  a  complica- 
tion of  the  enlarged  prostate. 

Contracture  or  sclerosis  of  the  internal  vesical  sphincter  is  characterized 
by  the  symptoms  of  prostatic  obstruction.  The  retention  is  even  more 
complete  and  the  suffering  incident  to  catheter  infection  more  marked. 
The  diagnosis  can  be  made  only  by  rectal  examination,  which  shows  often 
a  small,  hard  prostate,  and  by  the  passage  of  instruments  which  demon- 
strate a  short  posterior  urethra,  no  intravesical  prostatic  projections,  no 
lateral  deviation  of  the  sound,  and  obstruction  to  the  introduction  of 
the  instrument  only  '  at  the  vesical  neck. 

Malignant  tumor  of  the  prostate  is  characterized  by  precisely  the  symp- 
toms of  prostatic  enlargement,  differing  from  these  only  in  the  fact  that 


THE  URETHRA  665 

the  tumor  is  of  stony  hardness.  As  a  rule,  the  growth  is  small,  progresses 
slowly,  and  begins  in  the  posterior  portion  of  the  lateral  lobes.  Metas- 
tases to  the  bones,  particularly  those  of  the  lumbar  vertebrae,  may  occur 
before  the  local  symptoms  are  sufficiently  severe  to  lead  to  examination. 
The  growth  exhibits  a  tendency  to  extend  upward  along  the  course  of 
the  seminal  vesicles,  which  are  promptly  invaded. 

The  diagnosis  can  be  made  at  a  time  when  this  is  serviceable  to  the 
patient  only  by  excision.  In  its  late  development  hemorrhage,  pain, 
and  extensive  induration,  with  involvement  of  the  rectum  and  bladder, 
make  the  diagnosis  unmistakable. 


THE  URETHRA. 

The  urethra,  a  mucous  canal,  abundantly  supplied  with  glands  and 
follicles,  is  about  eight  inches  long  in  the  adult.  It  is  narrowest  at  the 
meatus  and  in  its  membranous  portion.  Just  behind  the  meatus  and 
in  its  prostatic  and  bulbous  portions  are  areas  of  physiological  dilata- 
tion. It  should  normally  take  a  32  sound,  except  for  the  natural  meatal 
narrowing,  which  may  be  so  small  that  a  22  cannot  be  passed  without 
traumatism. 

A  congenital  narrowing,  persisting  until  puberty  below  this  gauge, 
usually  gives  rise  to  some  bladder  irritability  and  favors  the  development 
of  urethral  discharge. 

Normally  there  should  be  no  discharge  from  the  urethra  except  a  slight 
transparent  mucus  following  prolonged  erection,  nor  should  there  be 
dribbling  of  urine  following  micturition  beyond  two  or  three  drops, 
readily  shaken  off. 

The  anterior  urethra,  six  inches  in  length,  is  surrounded  by  the 
erectile  tissue  of  the  spongy  body. 

The  posterior  urethra  in  its  first  three-quarters  of  an  inch  lies  between 
the  anterior  and  posterior  layers  of  the  triangular  ligament,  surrounded 
by  the  compressor  urethrse  muscle.  The  prostatic  portion  of  the  pos- 
terior urethra,  one  and  one-quarter  inches  long,  runs  through  the  upper 
portion  of  the  prostate  gland. 

Inflammation  of  the  anterior  urethra  is  characterized  by  discharge  from 
the  meatus,  pain  aggravated  by  the  act  of  urination  and  by  erection 
which  may  be  painful. 

Obstruction  to  the  free  passage  of  the  urine  is  characterized  by  slight 
urethral  discharge,  alteration  in  the  force  and  volume  of  the  stream 
passed,  dribbling  at  the  end  of  urination,  and  undue  frequency  of  the  act. 

Inflammation  of  the  posterior  urethra  is  characterized  by  pus  found 
both  in  the  first  and  the  second  portions  of  urine  if  this  be  passed  from 
a  full  bladder  in  two  parts.  This,  together  with  backache  in  the  sacral 
region  and  sexual  neurasthenia,  may  be  the  only  symptom  if  the  affec- 
tion be  chronic. 

In  acute  cases  there  is  pain,  usually  referred  to  the  meatus  or  just  behind 
it  and  felt  in  the  perineum,  anus,  and  down  the  inner  surfaces  of  the 


666  THE  OENITO-URINARY  ORGANS 

thighs,  severe  aching  in  the  same  region,  frequent  urgent  painful  urina- 
tion, with,  in  hyperacute  cases,  a  few  drops  of  blood  at  the  end  of  the 
act.     Frequently  there  are  recurring  erections  and  painful  emissions. 

Malformations  of  the  Urethra. — ^The  urethra  may  be  absent,  ob- 
literated, congenitally  strictured,  sacculated,  or  deficient  as  to  its  floor 
or  its  roof. 

Atresia  or  obstruction  of  an  otherwise  well-formed  urethra,  is  likely 
to  be  observed  near  the  meatus. 

Hypospadia. — Hypospadia,  or  deficiency  of  the  floor  to  the  urethra, 
is  comparatively  common.  The  urethra  may  terminate  at  the  base  of 
the  glans  (balanic),  between  the  glans  and  the  penoscrotal  junction 
(penile),  or  in  the  scrotal  cleft  or  perineum  (perineal).  The  balanic 
form  is  the  usual  one.  It  is  commonly  associated  with  a  normally 
placed  meatus  which  opens  into  a  blind  pouch. 

Epispadia. — Epispadia,  or  deficiency  of  the  urethral  roof,  is  a  rare 
deformity,  likely  to  be  complicated  by  exstrophy  of  the  bladder  or  other 
malformations.  Though  it  may  appear  simply  in  the  balanic  form, 
the  abnormal  opening  will  usually  be  found  just  in  front  of  the  pubic 
symphysis,  or  the  position  this  should  occupy,  since  it  may  be  congeni- 
tally absent. 

Narrowings  of  the  urethra,  whether  congenital  or  acquired,  are  char- 
acterized by  frequent,  difficult  urination. 

Congenital  pouches,  due  to  a  deficiency  of  the  spongy  body,  are  marked 
by  obvious  distention  at  the  time  of  urination  and  subsequent  dribbling 
as  the  pouch  is  gradually  emptied. 

Traumatic  subcutaneous  rupture  of  the  urethra  is  characterized  by 
pain,  urethral  hemorrhage,  the  immediate  formation  of  a  circumscribed 
tumor  at  the  seat  of  injury,  and  difficulty  in  passing  urine,  or  complete 
retention. 

When  this  rupture  has  been  accomplished  by  rough  instrumentation, 
immediate  free  bleeding  and  severe  pain  followed  by  a  mucopurulent 
discharge  may  be  the  only  symptoms  immediate  or  remote.  Exception- 
ally it  is  followed  by  extravasations  of  urine. 

When  the  rupture  is  due  to  force  from  without,  the  external  swelling 
increases  and  becomes  diffuse  and  is  shortly  (days)  followed  by  brawny, 
widespread  edema,  due  to  urinary  extravasation.  This  edema  in  the 
case  of  the  anterior  urethra  is  confined  to  the  scrotum,  the  penis,  and 
later  the  anterior  belly  wall. 

If  the  fibrous  envelope  of  the  spongy  body  has  not  been  torn  through, 
the  extravasation  may  not  involve  the  tissues  of  the  scrotum,  but  may 
travel  forward,  producing  cellulitis  and  gangrene  of  the  spongy  body  and 
the  glans.    More  commonly  it  forms  a  circumscribed  abscess. 

When  the  rupture  involves  the  posterior  urethra  (membranous  and 
prostatic  part)  there  is  neither  bleeding  from  the  meatus  nor  any  external 
sign  of  blood  tumor.  There  is  pain  and  complete  retention  or  the  strain- 
ing passage  of  bloody  urine.  The  urinary  extravasation  may  pass  for- 
ward taking  the  course  of  that  incident  to  rupture  of  the  anterior  urethra, 
or  may  infiltrate  the  pelvis,  giving  no  signs  other  than  the  constitutional 


THE  URETHRA  667 

ones  of  an  extensive  cellulitis  and  perhaps  a  boggy  swelling  detected  by 
rectal  examination. 

The  posterior  urethra  is  particularly  likely  to  be  torn  by  falling 
astride  of  a  narrow  surface,  such  as  the  edge  of  a  plank,  or  by  forces 
which  disrupt  the  pelvis.  The  bleeding,  then  takes  place  into  the 
surrounding  cellular  tissue  and  the  blood  flows  back  into  the 
bladder. 

The  absolute  diagnosis  of  urethral  rupture  is  made  by  instrumental, 
examination.  A  soft  instrument  will  be  arrested  at  the  seat  of  tear  if 
this  be  complete.  If  it  be  partial,  there  will  be  a  sense  of  obstruction 
which,  on  yielding,  allows  the  instrument  to  pass  into  the  bladder.  From 
this  clear  urine  will  be  drawn  in  the  case  of  tears  of  the  anterior  urethra; 
bloody  urine,  if  the  posterior  urethra  be  torn.  A  further  diagnosis  may 
be  made  by  direct  inspection  through  a  cystoscopic  tube. 

Diagnosis  of  extravasation  will  be  based  upon  the  rapid  extension  of 
brawny  edema  in  the  case  of  rupture  of  the  anterior  urethra,  possibly 
by  the  detection  of  pelvic  edema  on  rectal  examination  if  the  posterior 
urethra  be  involved,  associated  in  either  case  with  the  constitutional 
symptoms  of  septic  cellulitis. 

Foreign  bodies  in  the  urethra  give  rise  to  pain  and  obstruction  to  urin- 
ation. If  the  body  be  lodged  in  the  anterior  urethra  for  more  than 
twenty-four  hours,  there  will  be  a  blood-stained,  mucopurulent  discharge. 
If  of  sufficient  size,  it  can  usually  be  detected  by  external  palpation.  If 
the  foreign  body  be  a  calculus,  there  will  be  a  sudden  arrest  of  urine,  often 
accompanied  by  sharp  pain,  frequently  preceded  by  a  history  of  renal 
colic.  The  sound  and  the  urethroscope  will  not  only  prove  the  presence 
of  the  foreign  body,  but  usually  show  its  nature. 

Inflammatory  Affection  of  the  Urethra. — Urethritis.— The  only 
constant  symptom  of  urethritis  is  pus  either  escaping  from  the  meatus 
or  found  in  the  urine.  Inflammation  of  the  anterior  urethra  always 
causes  a  urethral  discharge  unless  the  secretion  of  pus  be  so  slight  that 
it  is  washed  away  by  each  act  of  micturition  before  a  sufficient  quantity 
accumulates  to  become  obvious  at  the  meatus. 

Discharge  from  the  posterior  urethra  usually  flows  back  into  the 
bladder,  hence  may  be  profuse  without  appearing  at  the  meatus. 

In  determining  from  what  part  of  the  urethra  the  pus  comes  the  patient 
is  directed  to  hold  his  urine  for  from  four  to  eight  hours;  this  is  con- 
veniently done  during  the  night,  the  test  being  made  at  the  time  of  his 
first  urination  on  waking  up.  He  is  directed  to  pass  his  urine  into  two 
glasses,  the  first  part  in  one,  the  last  part  in  another.  If  he  is  suffering 
from  a  free  urethral  discharge  involving  both  the  anterior  and  posterior 
urethra,  both  portions  of  urine  will  show  the  presence  of  pus,  but  usually 
there  will  be  much  less  in  the  last  portion.  If  the  posterior  urethra  is 
free  from  inflammation,  the  second  portion  of  urine  passed  will  fail  to 
show  pus. 

Symptoms  of  urethritis  other  than  pus  are  present  or  absent  in 
accordance  with  the  severity  of  the  inflammation,  and  bear  no  neces- 
sary relation. to  the  particular  form  of  infection 


668 ■  THE  GENITO-URINARY  ORGANS 

Aside  from  urorrhea,  characterized  by  a  moderate  mucous  discharge 
containing  few  leukocytes,  much  epithehum  and  the  bacteria  customarily 
found  in  the  normal  healthy  urethra,  and  developing  in  the  relaxed  and 
cachectic,  all  discharges  indicate  the  presence  of  inflammation. 

Acute  traumatic  urethritis,  i.  e.,  incident  to  instrumentation,  irritating 
injections  (common),  exceptionally  to  external  traumatism,  is  character- 
ized by  a  blood-stained,  purulent  discharge  which  usually  disappears  in 
three  to  seven  days.  The  discharge  following  strong  bichloride  injections 
may,  however,  be  quite  as  persistent  as  that  due  to  gonococcal  infection. 
The  diagnosis  is  made  from  the  history  of  the  case  and  by  excluding  the 
gonococcus  (microscopic  examination). 

Acute  urethritis  due  to  irritating  conditions  of  the  urine  (rare).  A 
mucopurulent  discharge,  with  slight  inflammatory  symptoms,  is  some- 
times due  to  the  ingestion  of  drugs  or  certain  articles  of  food,  such 
as  turpentine,  cubebs,  copaiba,  cantharides,  alcohol,  arsenic,  iodides, 
asparagus,  rhubarb,  strawberries,  and  fish.  Or  the  irritating  quality  of 
the  urine  may  be  due  to  high  fever,  to  rheumatism,  oxaluria,  or  phos- 
phaturia.  The  gonococcus  must  always  be  excluded  before  the  diag- 
nosis of  this  form  of  urethritis  can  be  formulated. 

Eruptive  Urethritis  (rare). — During  the  course  of  the  acute  exanthemata 
a  slight  urethral  discharge  is  at  times  observed.  Exceptionally  this  is  an 
expression  of  urethral  herpes,  in  which  case  it  is  likely  to  be  accompanied 
by  severe  pain  and  the  presence  of  herpetic  lesions  elsewhere. 

Simple  infectious  urethritis,  at  times  called  abortive  gonorrhea,  follows 
much  the  early  course  of  gonorrhea,  and  is  usually  due  to  a  similar 
form  of  exposure.  It  runs  a  short  course,  unattended  with  complications. 
Exceptionally  it  is  as  prolonged  and  complicated  as  the  most  obstinate 
infection.     Gonococci  are  not  found. 

Gonococcic  Urethritis. — This,  the  commonest  form  of  urethral  inflamma- 
tion, is  characterized  by  an  acute  urethral  inflammation  which  comes  on 
in  from  one  to  twelve,  usually  three,  days  after  exposure.  It  becomes 
total  within  the  first  week.  The  diagnosis  depends  upon  finding  the 
gonococcus. 

Urethral  and  periurethral  abscess,  common  complications  of  both  gono- 
coccal and  instrumental  urethritis,  are  characterized  by  nodulation  or 
induration  along  the  urethral  course  and  chordee,  followed  by  softening 
and  discharge  either  internally,  externally,  or  in  both  directions,  excep- 
tionally leading  to  urinary  fistula  or  extravasation,  and  always  followed 
by  stricture. 

Cowperitis. — Suppuration  of  Cowper's  gland,  situated  as  it  is  between 
the  two  layers  of  the  triangular  ligament  below  the  urethra,  is  attended  by 
severe  perineal  pain,  aggravated  by  defecation,  and  especially  so  by  the 
terminal  act  of  micturition,  perineal  tenderness  so  great  as  to  make 
sitting  or  walking  difficult,  and  the  presence  of  a  swelling  behind  the  bulb, 
most  readily  detected  by  a  finger  passed  just  within  the  external  sphincter 
and  pressed  upward  and  forward.  The  tumor  is  found  to  one  side  of  the 
median  line  unless  both  glands  are  involved,  and  lies  in  front  of  the 
prostate — this  is  diagnostic. 


THE   URETHRA  669 

The  increased  swelling  incident  to  suppuration  causes  complete  reten- 
tion of  urine  and  marked  aggravation  of  all  symptoms.  The  abscess 
usually  ruptures  externally.  Exceptionally  into  the  urethra.  It  is  not 
complicated  by  urinary  extravasation.  When  the  gland  is  not  destroyed 
by  abscess  formation  the  inflammation  may  become  chronic,  indefinitely 
prolonging  the  urethritis. 

Pneumococcic  and  diphtheritic  urethritis  (rare)  are  overshadov^^ed  by 
the  constitutional  symptoms  of  the  major  disease.  The  diagnosis  must 
be  made  by  the  finding  of  the  specific  organisms  in  the  discharge. 

Syphilitic  urethritis  may  be  due  to  either  primary,  secondary,  or 
tertiary  syphilis.  In  its  acute  or  subacute  form  it  is  always  due  to 
chancre,  which  is  usually  placed  not  deeper  than  half  an  inch  from  the 
meatus.  There  is  moderate  discharge,  swelling  about  the  frenum, 
and  some  obstruction  to  urination.  Though  there  may  be  frequency 
because  of  obstruction,  other  posterior  symptoms  do  not  develop.  In- 
guinal adenopathy  or  general  eruption  usually  appears  before  the  true 
nature  of  the  affection  is  recognized. 

The  long  incubation  (never  less  than  two  weeks),  the  chronic,  non- 
progressive nature  of  the  affection,  and  particularly  bilateral,  poly- 
glandular, painless  enlargement  of  the  inguinal  glands  should  suggest  an 
examination  with  the  meatoscope  or  urethroscope,  which  would  establish 
the  diagnosis  by  showing  the  presence  of  a  rounded,  indolent  ulcer.  At 
times  the  mucopurulent  discharge  and  obstructive  swelling  are  not 
sufficient  to  excite  attention,  in  which  case  secondary  symptoms  may 
occur  without  suspicion  upon  the  part  of  the  patient  as  to  the  true  seat  of 
infection. 

Chancroidal  urethritis  is  always  accompanied  by  an  ulceration  at  or 
near  the  meatus,  exliibiting  the  characteristics  of  a  chancroid. 

The  inflammation  is  limited  to  the  region  of  the  meatus,  there  are  no 
symptoms  of  posterior  urethritis,  and  no  gonococci  are  found. 

Chronic  Urethritis. — The  causes  of  chronic  urethritis  are  stricture, 
persistence  of  infection  in  glands  and  follicles,  tuberculosis,  syphilis, 
and  urethral  polypi. 

Stricture,  even  though  it  be  of  large  caliber,  is  the  commonest  cause  of 
chronic  urethral  discharge.  It  is  best  detected  by  square-shouldered 
metal  bougies.  An  inflammation  once  started,  a  narrow  meatus  acts  as 
a  stricture.  If  the  meatus  be  once  passed,  an  unstrictured  urethra  should 
take  a  32  F.  bulbous  bougie;  this  will  be  resisted  by  the  accelerator  urinae 
muscle  and  stopped  by  the  compressor  urethrse.  On  withdrawal  it  should 
not  at  any  point  give  a  distinct  jump,  such  as  comes  when  it  is  made  to 
clear  an  obstruction. 

Next  in  order  of  frequency  as  a  cause  of  chronic  urethral  discharge 
comes  persistent  infection  of  the  glands  and  follicles.  These  act  as  foci 
for  recurring  subacute  outbreaks.  The  diagnosis  must  be  made  by  direct 
examination.  After  irrigation  of  the  anterior  urethra  a  bulbous  bougie 
of  full  caliber  is  passed  to  the  membranous  urethra  and  withdrawn  with 
a  gentle  swabbing  motion;  this  milks  the  pus  from  the  inflamed  follicles, 
bringing  it  out  on  the  shoulder  of  the  bulb. 


670  THE  GENITO-URINARY  ORGANS 

From  the  posterior  urethra  after  partial  micturition  massage  of  the 
prostate  will  usually  bring  an  abundant  supply  of  pus.  A  direct  urethro- 
scopic  examination  may  be  essential  for  an  absolute  diagnosis. 

Tuberculous  urethritis  is  characterized  by  apparently  causeless,  slight, 
persistent  urethral  discharge,  which  is  not  bettered  by  local  treatment. 
Diagnosis  is  sometimes  made  by  the  finding  of  the  tubercle  bacillus, 
usually  by  the  discovery  of  tuberculous  lesions  in  other  situations, 
particularly  in  the  seminal  vesicles  or  epididymis.  With  this  discharge 
there  is  usually  associated  frequency  of  urination;  later,  tenesmus,  pain 
and  slight  hematuria. 

Syphilitic  urethritis  as  a  manifestation  of  the  urethral  localization  of 
the  secondary  eruption  of  syphilis  (rare)  is  chronic,  indolent,  and 
practically  without  symptoms  except  for  the  discharge.  The  history, 
exclusion  of  other  causes,  and  association  with  other  more  character- 
istic lesions  of  the  infection  will  lead  to  a  correct  diagnosis. 

Urethral  Polyps. — Urethral  polyps  (rare)  are  characterized  by  per- 
sistent moderate  discharge;  the  diagnosis  must  be  made  by  means  of 
the  urethroscope. 

THE  BLADDER. 

The  bladder,  when  healthy,  has  no  absorbing  power.  It  holds  with 
comfort  about  twelve  ounces;  with  slight  distress,  a  pint.  It  is  pro- 
vided with  two  sphincters.  The  internal  vesical  sphincter  is  in  a 
condition  of  tonic  contraction  until  the  viscus  contains  from  four  to  six 
ounces  when  it  dilates,  making  the  prostatic  urethra  a  portion  of  the 
bladder  cavity;  the  urine  is  then  retained  by  the  external  sphincter, 
i.  e.,  the  compressor  urethrse  muscle. 

The  vesical  mucous  membrane  is  made  up  of  flat  epithelium  placed 
on  a  layer  of  cylindrical  cells.  It  is  of  a  yellowish  color,  and,  because 
of  the  distensibility  of  the  organ,  exhibits  many  plications.  The  ureteral 
orifices  of  the  bladder  are  protected  against  regurgitation  by  valves 
which  become  increasingly  competent  in  proportion  to  intravesical 
tension. 

Most  men  empty  the  bladder  on  rising  in  the  morning,  after  breakfast, 
during  defecation,  at  noon,  late  in  the  afternoon,  and  on  going  to  bed, 
passing  from  six  to  twelve  ounces  at  each  act  of  urination. 

Transitory  undue  frequency  of  urination  in  the  absence  of  vesical  or 
renal  lesions  follows  the  excessive  ingestion  of  fluid,  the  use  of  diuretic 
drugs  and  articles  of  food,  anxiety  or  any  vivid  emotion,  or  change  from 
warm  to  cold  weather. 

Persistent  undue  frequency  of  urination  may  be  an  expression  of  hyper- 
secretion, as  in  diabetes  or  chronic  nephritis.  Unassociated  with 
hypersecretion,  it  may  be  due  to  irritating  qualities  of  the  urine,  pro- 
ducing congestion  and  hence  exaggerated  reflexes.  This  symptom  is 
common  when  the  urine  contains  blood,  phosphates,  or  oxalates,  or  is 
highly  concentrated  as  the  result  of  fever  or  indigestion. 

Incontinence  of  urine,  unattended   by  vesical   or  renal  lesions,  is 


THE  BLADDER  671 

characterized  by  the  painless  escape  of  urine  with  or  without  the 
consciousness  of  the  individual. 

In  its  accidental  form  the  affection  is  often  called  a  weak  bladder. 
The  discharge  is  explosive,  and  comes  from  a  sudden  abdominal  strain, 
which  takes  the  sphincters  off  their  guard,  as  in  the  act  of  laughing  or 
coughing.  In  its  transient  form  incontinence  follows  anesthesia,  drunken- 
ness, sometimes  prolonged  involuntary  retention. 

Persistent  incontinence,  independent  of  bladder  lesion,  is  physiological 
in  children  up  to  the  age  of  one  or  two  years.  In  those  of  older  growth 
the  incontinence  may  be  due  to  habit  or  degeneracy;  if  it  be  both  diurnal 
and  nocturnal,  it  is  probably  dependent  upon  an  organic  lesion. 

Nocturnal  incontinence  occurring  in  an  adolescent  or  adult  without 
local  inflammatory  or  reflex  cause  is  strongly  suggestive  of  epilepsy  or 
beginning  ataxia.  Visceral  crises  limited  to  the  urinary  organs  occur  in 
tabes. 

Attacks  of  profuse  hematuria  without  other  symptoms  may  be  due 
to  vesical  varices,  to  aneurysm  of  the  renal  arteries,  or  to  an  essential 
renal  hemorrhage.  These  conditions  are  all  extremely  rare.  The  usual 
cause  is  a  bladder  tumor,  nor  is  the  freedom  of  bleeding  an  index  to  the 
size  of  the  tumor. 

Bacteriuria. — ^The  urine  may  be  swarming  with  bacteria  without  pus 
admixture. 

The  organism  usually  causative  of  simple  bacteriuria  is  the  Bacillus 
coli  communis.  It  gains  entrance  from  the  intestine  in  cases  of  chronic 
constipation,  acute  enteritis,  dysentery,  or  typhoid  fever. 

Typhoid  bacteriuria  exists  in  from  20  per  cent,  to  30  per  cent,  of  cases 
of  typhoid  fever,  usually  in  pure  culture,  appearing  generally  in  the  second 
to  the  third  week  of  the  disease,  often  associated  with  albuminuria, 
without  pus,  and  rarely  producing  the  morbid  changes  of  cystitis,  even 
though  it  persist  for  years. 

With  the  exception  of  hypersecretion  of  mucus  and  slight  albuminuria, 
simple  bacteriuria  is  unattended  with  inflammatory  symptoms.  Under 
local  favoring  conditions  it  may  become  converted  into  pyuric  bacteriuria. 
Microscopic  examination  will  at  once  determine  the  presence  or  absence 
of  pus  in  quantity. 

The  local  symptoms  when  present  are  generally  slight — frequency  of 
micturition,  mild  ardor  urinae,  occasionally  incontinence,  and,  in  children, 
nervous  disturbances.  There  may  be  a  slight  urethral  discharge.  So 
long  as  the  epithelium  of  the  urinary  tract  remains  healthy  there  is  no 
absorption  of  the  bacterial  toxins.  If  from  imperfect  drainage  the 
bladder  epithelium  loses  its  vitality,  absorption  occurs  and  mild  fever, 
lassitude,  and  digestive  and  nervous  disturbances  appear. 

Pyuria  always  implies  an  area  of  suppuration  in  some  part  of  the  genito- 
urinary tract,  and  is  generally  associated  with  symptoms  referable  to  its 
location. 

Malformations  and  Malpositions  of  the  Bladder. — ^The  bladder  may 
be  absent,  the  ureters  opening  into  the  urethra,  the  vagina,  the  rectum, 
or  the  umbilicus.     It  may  be  multiple,  single,  with  a  central  septum 


672 


THE  GEN  IT  0-U  BINARY  ORGANS 


dividing  it  into  two  portions,  which  may  or  may  not  communicate  with 
each  other,  or  sacculated. 

The  usual  malformation  is  exstrophy,  or  absence  of  a  portion  of  (he 
bladder  wall,  usually  the  anterior  one.  It  is  most  often  observed  in  male 
children,  and  is  due  to  failure  of  the  lateral  portions  of  the  urogenital 
cleft  to  unite;  hence  the  deficiency  is  not  only  of  the  bladder,  but  also  of 
the  musculocutaneous  abdominal  parietes  and  the  pelvic  girdle,  the  pubes 
not  meeting  in  the  middle  line  to  form  the  symphysis. 


Fig.  434 


Exstrophy  of  bladder  and  epispadia. 


-  This  deformity  is  associated  with  epispadia  in  the  male  and  split  clitoris 
in  the  female.  There  is  also  commonly  associated  with  it  complete 
double  inguinal  hernia,  rudimentary  prostate,  and  ectopic  testes. 

The  diagnosis  is  obvious,  the  bulging,  dark  red  surface  of  intensely 
inflamed  mucous  membrane  surrounded  by  an  area  of  cicatrix-like 
tissue  uniting  its  borders  to  the  skin  being  sufficiently  characteristic. 
Projections  marking  the  ureteral  orifice  can  usually  be  found  by  the  escape 
of  urine  which  comes  from  them  in  jets. 

Occasionally,  as  a  congenital  defect,  the  urachus  remains  patent,  the 
urine  escaping  through  the  umbilicus.  In  this  mucous  channel  urinary 
concretions  and  suppurating  pouches  may  form  and  may  persist  after 
closure  of  the  communication  with  the  bladder. 

Hernia  of  the  Bladder. — Hernia  implies  a  protrusion  of  the  bladder  wall 
along  the  track  usually  taken  by  intestinal  hernia.  The  inguinal  cysto- 
cele  is  the  common  form,  though  there  are  instances  of  obturator,  crural, 
and  perineal  vesical  hernia.     The  herniated  portion  of  the  bladder  usually 


THE  BLADDER  673 

presents  thin  walls  and  is  often  surrounded  by  considerable  fat.  Some- 
times it  appears  as  a  diverticulum  with  an  extremely  small  opening  into 
the  general  vesical  cavity.  Because  of  stagnation  of  urine  in  these  diver- 
ticula calculi  may  form. 

These  hernia  are  caused  by  the  peritoneal  pull  of  a  preceding  intestinal 
hernia,  and  are  characterized  by  a  dull,  fluctuating  tumor  in  the  inguinal 
region,  varying  in  size  with  the  quantity  of  urine  contained  in  the  bladder. 
Where  the  communication  between  the  herniated  portion  and  the  general 
cavity  is  small  there  may  be  no  immediate  change  in  the  size  of  the  herni- 
ated portion  on  micturition.  If,  however,  the  patient  lies  down  and  sub- 
jects the  mass  to  gentle  manipulation  it  markedly  diminishes  in  size,  and 
almost  immediately  he  can  pass  a  further  quantity  of  urine.  Furthermore, 
the  flaccid  and  inconspicuous  swelling  becomes  tense  and  full  when 
fluid  is  forced  into  the  bladder. 

As  a  rule,  the  herniated  portion  of  the  bladder  is  small  and  offers  no 
symptoms  other  than  those  associated  with  an  irreducible  omental  hernia. 
It  is  usually  unexpectedly  encountered  during  hernia  operations.  Its 
presence  should  be  suspected  when  in  the  effort  to  close  the  hernial  orifice 
an  undue  amount  of  fat  is  brought  into  sight.  These  vesical  hernias  are 
rarely  invested  with  a  complete  layer  of  peritoneum. 

Traumatisms. — Wounds  of  the  bladder,  if  large  and  open,  are  char- 
acterized by  the  escape  of  urine  through  them.  If  small,  by  the  passage 
of  bloody  urine,  and  by  the  results  of  cystoscopic  examination,  together 
with  a  consideration  of  the  nature  of  the  vulnerating  body  and  its  direc- 
tion of  travel.     Usually  there  is  temporary  retention  of  urine. 

The  complications  of  these  wounds  are  peritonitis,  pelvic  cellulitis, 
fistulse,  and  calculi;  the  latter  from  the  lodgement  of  a  foreign  body  in  the 
bladder  too  large  to  be  passed  per  urethram.  If  there  be  free  bleeding 
from  the  bladder,  this  in  itself  is  indicative  of  wound  and  would  justify 
an  exploratory  operation. 

Contusion  of  the  bladder  is  characterized  by  retention,  tenesmus,  pain, 
tenderness,  and  the  passage  of  blood-stained  urine  and  clots  following 
traumatism.  Shock  is  usually  wanting.  It  is  possible  that  in  a  previously 
diseased  bladder  hemorrhage  may  have  been  severe  and  continued.  Con- 
tusion with  such  symptoms  is  extremely  rare. 

The  diagnosis  must  be  made  from  rupture.  Theoretically,  this  can 
be  done  by  injecting  a  measured  quantity  of  fluid  into  the  bladder  and 
withdrawing  it.  If  all  that  has  been  injected  flows  through  the  catheter, 
it  is  obvious  there  can  be  no  large  rent  in  the  wall. 

Rupture  of  the  Bladder.— Rupture  of  the  bladder  is  particularly  common 
in  drunkards.  Probably  because  they  are  frequently  subjected  to  trauma 
and  often  have  overfull  bladders.  It  is  observed  as  a  result  of  fracture 
of  the  pelvis  and  kicks  in  the  belly.  Occasionally  it  is  caused  by  muscular 
action,  such  as  defecation,  urination,  or  heavy  lifting.  It  has  occurred 
at  times  from  moderate  distention  of  a  bladder  lifted  forward  by  an 
inflated  bag  in  the  rectum,  with  the  idea  of  facilitating  a  suprapubic 
cystotomy.  The  rupture  may  be  intraperitoneal  or  extraperitoneal, 
usually  the  former. 

43  ..  ;  . 


674  THE  GENITO-URINARY  ORGANS 

The  characteristic  symptoms  are  a  sense  of  something  having  ruptured, 
agonizing  hypogastric  pain,  constant  desire  to  urinate,  with  either  the  loss 
of  power  to  do  so  or  the  passage  of  blood-stained  urine,  and  severe 
shock.  In  the  course  of  hours,  sometimes  days,  there  will  follow  either 
the  symptoms  of  general  peritonitis  or  of  pelvic  cellulitis,  dependent  upon 
the  seat  of  rupture. 

There  may  be  no  immediate  symptoms  other  than  temporary  inability 
to  urinate,  and  later  the  passage  of  bloody  urine.  Nor  does  the  extrava- 
sation of  a  small  amount  of  sterile  urine  inevitably  cause  peritonitis  or 
septic  cellulitis. 

Diagnosis  is  founded  upon  the  symptoms  and  the  results  of  direct 
examination. 

After  flushing  the  anterior  urethra  with  an  antiseptic  solution  a  sterile 
silver  catheter  of  as  large  size  as  can  be  passed  is  introduced  into  the 
bladder.  If  this  draws  off  bloody  urine  and  clot,  the  probability  of  rup- 
ture is  strong.  If,  on  manipulation  of  the  shaft,  so  that  the  tip  is  made 
to  traverse  the  inner  surface  of  the  bladder,  this  tip  repeatedly  catches 
at  one  point,  and  apparently  can  be  passed  through  the  bladder  wall, 
so  that  it  can  be  felt  immediately  beneath  the  skin  in  the  hypogastric 
region  or  close  to  the  rectal  mucous  membrane,  there  can  be  no  doubt 
as  to  the  presence  of  rupture.  Through  the  silver  catheter,  after  it  has 
drained  the  bladder  of  its  contents,  a  measured  quantity  of  sterile  salt 
solution  can  be  injected.  If  there  be  no  rupture,  this  should  all  flow 
out  again.  This  test  is  not  infallible.  Doubt  should  be  resolved  by 
suprapubic  cystotomy.  The  cystoscope  will  be  most  serviceable  in  dis- 
proving the  existence  of  rupture,  since  for  its  successful  use  the  bladder 
must  hold  four  ounces  of  a  clear  fluid. 

Cystitis. — Cystitis,  or  inflammation  of  the  bladder,  is  due  to  infection. 
It  is  extremely  difficult  to  infect  the  normal,  properly  vascularized  mucous 
membrane  of  the  bladder.  When  this  becomes  greatly  congested,  as  from 
retention  of  urine,  infection  is  made  easy. 

As  it  appears  clinically,  cystitis  may  be  acute  or  chronic,  and  in 
accordance  with  the  depth  of  the  structures  involved  it  may  be  catarrhal 
or  interstitial. 

The  causes  of  vesical  congestion  are  retention  of  urine,  trauma, 
whether  this  be  due  to  external  injury,  passage  of  an  instrument,  or 
presence  of  a  stone  or  tumor,  surface  chilling,  frequently  repeated  and 
straining  micturition,  abnormal  conditions  of  the  urine,  constipation, 
prolonged  sexual  excitement  or  excess,  cardiac  weakness,  or  lesion  of  the 
central  nervous  system. 

The  exciting  cause  of  cystitis  is  local  infection,  usually  due  to  catheter 
infection  or  urethritis;  exceptionally  to  pericystic  suppurating  foci,  or 
carried  by  the  blood  or  lymph  vessels.  Infection  by  way  of  the  urine 
may  take  place  secondary  to  involvement  of  the  kidneys,  although 
healthy  kidneys  may  eliminate  pyogenic  organisms. 

The  colon  bacillus  is  the  usual  infecting  agent;  less  frequently  the 
pyogenic  staphylococci  and  streptococci  and  the  Bacillus  proteus  vul- 
garis. Excepting  for  the  trigonum,  the  vesical  mucosa  is  to  an  extent 
immune  to  the  gonococcus. 


THE  BLADDER  675 

All  the  pyogenic  germs  and  many  others  found  in  the  urine  of  cystitis 
produce  ammoniacal  fermentation,  providing  the  urine  is  retained 
more  than  a  few  hours  in  the  bladder.  This  increases  the  irritating 
effect  of  retained  urine  upon  the  already  inflamed  vesical  mucous  mem- 
brane. Ammoniacal  urine  is  diagnostic  of  infection  and  of  at  least 
partial  retention,  though  this  may  occur  in  the  renal  pelvis. 

The  symptoms  of  cystitis  are  those  of  posterior  urethritis,  except  that 
in  acute  cases  there  is  marked  suprapubic  tenderness. 

The  frequent  painful  passage  of  purulent  urine  constitutes  the  major 
symptom.     In  chronic  cases  pyuria  may  be  the  only  symptom. 

With  the  pus  there  is  often  found  blood  and  always  an  excess  of  mucus 
and  bladder  epithelium. 

When,  together  with  pain,  frequency,  urgency,  and  pyuria  the  bladder 
is  tender  on  suprapubic  and  rectal  palpation,  when  the  urine  passed  in 
three  portions  shows  greatest  pus  turbidity  in  the  last,  when  the  flat 
bladder  epithelium  is  very  abundant,  when  intravesical  injections  show 
that  the  bladder  is  hypersensitive  to  tension,  and  when  the  urine  at  the 
time  of  being  passed  is  ropy  and  ammoniacal,  the  diagnosis  of  cystitis 
can  be  safely  made.  A  large  amount  of  mucopus  in  the  urine  (settling 
out  \  on  standing)  in  the  absence  of  pyelitis  is  diagnostic  of  cystitis. 
Examination  with  the  cystoscope  is  conclusive.  When  this  is  imprac- 
ticable there  may  be  introduced  into  the  bladder  a  self-retaining 
catheter,  so  stretched  over  a  carrier  that  its  flange  is  obliterated.  On 
withdrawing  the  carrier  the  elasticity  of  the  rubber  causes  the  flange 
to  resume  its  shape.  The  catheter  is  then  drawn  out  until  the  flange 
catches  against  the  internal  vesical  sphincter,  and  is  secured  in  place 
by  a  small  weight  attached  to  its  free  end.  The  bladder  is  thoroughly 
washed  out  with  normal  salt  solution,  and  the  catheter  is  left  in  place  for 
an  hour,  the  urine  which  flows  through  it  being  collected.  Pus  in  quantity 
found  in  this  urine  must  come  from  the  bladder,  ureters,  or  kidneys. 

If  the  kidneys  are  neither  tender  nor  obviously  enlarged,  the  bladder 
origin  of  the  pus  is  probable.  The  infecting  organism  must  be  deter- 
mined by  microscopic  examination  of  the  pus. 

The  essential  point  in  the  diagnosis  of  cystitis  is  to  determine  its  cause. 
Cystitis  once  started  in  a  bladder  subject  to  retention  because  of  urethral 
obstruction  (enlarged  prostate,  sclerosed  internal  vesical  sphincter, 
stricture)  persists  until  the  obstruction  is  relieved.  So  long  as  a  bladder 
contains  tumor,  calculus,  or  foreign  body  there,  is  no  tendency  toward 
cure.  In  the  absence  of  these  causes  of  chronic  congestion  or  urethral 
obstruction,  cystitis  has  no  natural  tendency  to  persist;  hence,  if  after 
removal  of  the  apparently  predisposing  factor  the  infection  remains 
obstinate  to  treatment,  this  in  itself  constitutes  a  good  reason  for  sus- 
pecting tuberculosis. 

Vesical  Calculus. — The  large  majority  of  calculi  are  formed  of  uric 
acid  and  the  urates,  the  phosphatic  and  mixed  calculi  come  next  in  order 
of  frequency,  and  last  come  the  oxalates  and  rarer  forms. 

Vesical  calculi  are  found  from  fetal  life  to  old  age.  They  are  commonest 
in  poor  male  children  and  rich  old  men,  and  are  at  times  preceded  by 


676  THE  GENITO-URINARY  ORGANS 

a  history  of  gravel,  oxaluria,  heavy  deposits  in  the  urine,  hematuria, 
or  renal  coHc. 

The  symptoms  characteristic  of  calculus  of  the  bladder  are  identical 
with  those  of  posterior  urethritis  or  cystitis.  Indeed,  the  latter  is  often 
the  lesion  which  causes  the  pain.  Frequent  urination  is  most  marked 
in  the  daytime,  is  aggravated  by  motion,  and  relieved  by  rest.  In  the 
case  of  small,  freely  movable  stones  urination  may  be  accompanied  by 
so  much  tenesmus  as  to  produce  prolapse  of  the  bowel,  or  there  may 
be  sudden  stoppage  of  the  urine  during  the  passage  of  a  full-sized 
stream,  which  may  be  obviated  by  having  the  patient  assume  the  dorsal 
decubitus  during  urination.  This  symptom  is  suggestive,  though  not 
diagnostic,  since  inflammation  in  itself  may  produce  reflex  spasm  causing 
the  same  symptom. 

The  pain  of  vesical  calculus,  usually  referred  to  the  end  of  the  penis, 
or  more  accurately  to  the  lower  urethral  surface,  about  an  inch  behind 
the  glans,  is  also  common  to  posterior  urethritis.  This  symptom  is  not 
observed  in  old  prostatics  suffering  from  stone,  because  the  backward 
projection  of  the  prostate  prevents  the  calculus  from  coming  in  contact 
with  the  vesical  neck.  It  is  especially  marked  in  children  and  induces 
in  them  that  characteristic  pulling  on  the  penis  which,  when  associated 
with  rectal  prolapse,  crying  during  urination,  frequency  of  the  act,  and 
pus  and  blood  in  the  urine,  is  diagnostic  of  stone. 

The  pain  of  stone  is  usually  terminal,  as  is  the  hematuria,  which  is 
slight.  The  pain  may  be  referred  to  the  perineum,  hypogastric  region, 
the  small  of  the  back,  the  outer  surfaces  of  the  thighs,  the  lower  leg,  or 
the  foot. 

The  congestion  incident  to  stone  predisposes  to  infection,  which  is 
usually  produced  by  instrumentation. 

The  diagnosis  is  based  upon  physical  examination,  since  stone  may 
exist  in  the  absence  of  all  these  symptoms,  even  blood  not  being  found 
on  microscopic  examination  of  the  urine. 

The  examination  is  conducted  by  bimanual  palpation  The  patient 
having  passed  his  urine,  is  directed  to  lean  well  forward  with  the  elbows 
on  a  table  or  the  hands  resting  on  a  chair,  with  the  legs  moderately 
separated  and  the  abdominal  muscles  relaxed.  Thereafter  he  is  placed 
upon  his  back  with  the  shoulders  and  the  thighs  flexed.  In  each  position 
the  index  finger  of  one  hand  is  passed  into  the  rectum,  the  fingers  of  the 
other  press  above  the  pubis.  In  children  a  stone  of  moderate  size  can 
be  felt.  A  large  stone  can  nearly  always  be  detected  in  adults  unless 
there  is  an  associated  prostatic  hypertrophy. 

Instrumental  examination  is  inaugurated  by  an  antiseptic  irrigation  of 
the  anterior  urethra.  Thereafter  a  stone  searcher,  fully  10  inches  long, 
with  a  short  curve  near  the  tip,  is  introduced.  This  searcher  should  be 
hollow,  to  permit  of  evacuation  of  the  bladder  contents.  When  the 
searcher  is  first  passed  the  bladder  should  be  well  distended;  as  the 
examination  proceeds  the  urine  should  be  allowed  slowly  to  flow  out. 
When  using  this  instrument  the  patient  is  placed  in  the  flat  dorsal  posi- 
tion.    When  the  prostate  is  greatly  enlarged  and  the  bladder  not  greatly 


THE  BLADDER  677 

distended,  he  is  put  in  the  Trendelenburg  posture.  The  introduction 
of  the  curve  of  the  instrument  within  the  bladder  is  usually  painful  and 
requires  that  its  shaft  should  be  depressed  well  below  the  horizontal  plane 
of  the  body.  The  searcher  has  not  satisfactorily  entered  the  bladder 
until  at  least  eight  inches  of  its  shaft  have  passed  within  the  meatus 
and  it  can  be  rotated  almost  completely  about  its  long  axis  without  the 
slightest  sense  of  resistance. 

The  bladder  having  been  entered,  the  sound  is  pushed  backward 
and  drawn  forward  again  with  comparatively  rapid  motions,  the  handle 
being  elevated  and  depressed  and  carried  first  to  one  side,  then  the 
other.  It  is  at  no  time  sufficiently  withdrawn  to  engage  the  curve  of 
the  instrument  in  the  prostatic  urethra.  Failing  thus  to  detect  the 
stone,  the  sound  is  introduced  to  its  full  extent,  and  its  tip  is  flicked 
from  side  to  side  by  a  rapid  rotary  motion  of  the  handle.  This 
motion,  begun  with  the  inner  end  of  the  sound  at  the  bas-fond,  is  con- 
tinued while  the  sound  is  gently  drawn  outward  until  the  curve  reaches 
the  vesical  neck.  If  the  stone  is  not  found  in  this  manner,  the  tip  is 
again  introduced  as  far  as  it  will  go,  is  turned  gently  toward  the  floor 
of  the  bladder  and  rotated  quickly  from  side  to  side,  while  the  instru- 
ment is  gradually  withdrawn  until  its  curve  catches  the  vesical  neck. 
The  anterior  wall  of  the  bladder  may  be  explored  by  pressing  it  down  by 
suprapubic  pressure  until  the  tip  of  the  instrument  can  reach  its  surface. 
When  there  is  an  enlarged  prostate  and  the  base  of  the  bladder  is  de- 
pressed, it  is  well  to  elevate  this  portion  of  the  viscus  by  a  finger  intro- 
duced into  the  rectum,  while  the  exploration  with  the  sound  is  continued. 

If  these  manipulations  fail  to  detect  the  stone,  the  urine  should  be  grad- 
ually withdrawn  and  they  should  be  repeated  as  the  bladder  contracts. 
A  sharp  click  denotes  the  presence  of  a  stone.     It  is  both  felt  and  heard. 

This  examination  may  fail  to  detect  the  stone  because  it  is  small, 
encysted,  lies  in  a  diverticulum,  is  fixed  by  adhesions  to  the  anterior 
wall  of  the  bladder,  is  covered  with  lymph  or  blood  clot,  or  is  lodged  in  a 
pocket  or  sinus  lying  between  the  vesical  mucosa  and  the  prostate. 

The  click  may  be  simulated  by  incrustation  of  a  tumor  with  lime  salts, 
by  a  fasciculated  and  incrusted  condition  of  the  bladder. 

If  there  is  reason  to  suppose  the  calculus  is  a  small  one,  as  when  a 
recent  ureteral  colic  shows  it  has  not  been  long  in  the  bladder,  the  exami- 
nation should  be  conducted  with  the  small  tube  of  an  evacuating  litho- 
trite.  The  bladder  is  distended,  in  the  case  of  an  adult  with  four  to 
six  ounces  of  fluid,  the  evacuator  of  the  lithotrite  is  filled  with  protargol 
solution,  1  to  2000,  the  tube  is  introduced  into  the  bladder,  connected 
with  an  evacuator,  and  the  stopcock  is  turned  on.  Then  by  squeezing 
the  bulb  of  the  evacuator  one  or  two  ounces  of  fluid  is  injected  into  the 
bladder;  on  relaxing  the  pressure  a  similar  quantity  is  rapidly  sucked 
out.  This  will  draw  a  small  stone  into  the  eye  of  the  evacuator,  making 
a  sharp  click.  The  eye  of  the  evacuator  should  be  carried  systematic- 
ally into  various  portions  of  the  bladder  in  making  this  examination. 

Cystoscopic  examination  conducted  by  an  expert  in  the  use  of  the 
instrument  is  to  the   surgeon  the  most  satisfactory  way  of  making  a 


678  THE  GEN  IT  0-U  BINARY  ORGANS 

diagnosis.     To  the  patient  the  x-ray  is  the  easiest  way  and  is  fairly 
rehable  in  its  results. 

Foreign  Bodies  in  the  Bladder. — Foreign  bodies  in  the  bladder 
may  cause  no  symptom  until  they  become  complicated  by  cystitis,  when 
incrustation  with  urinary  salts  promptly  occurs.  The  symptoms  are 
those  of  stone,  from  which  a  differentiation  can  be  made  only  by  the 
a;-rays  or  cystoscopic  examination.     Often  the  history  is  diagnostic. 

Tuberculosis  of  the  Bladder. — Nearly  always  secondary  to  infection  of 
the  kidneys,  it  may  be  unsuspected  until  microscopic  examination  of  the 
urine  shows  the  presence  of  blood  and  mucus,  with  an  excess  of  leuko- 
cytes greatly  deformed  and  free  from  bacteria.  Usually  there  is  a  noc- 
turnal and  diurnal  frequency  not  sufficiently  pronounced  to  excite 
attention.  At  times  there  is  slight  terminal  hematuria  obvious  to  the 
patient. 

With  the  onset  of  cystitis,  which  almost  inevitably  develops  and  is 
frequently  incident  to  the  first  catheterization  practised  for  diagnosis  of 
the  cause  of  frequency,  there  is  pain,  greatly  aggravated  by  the  act  of 
micturition,  urgency,  pyuria,  and  either  microscopic  or  macroscopic 
blood.  The  pain  of  tuberculous  cystitis  is  more  harassing,  persistent, 
and  obstinate  to  treatment  than  that  from  any  other  cause,  with  the 
exception  of  calculus.  It  is  due  in  great  part  to  spasm.  The  coincident 
loss  of  weight  and  deterioration  of  physical  condition  are  partly  incident 
to  pain,  but  mainly  to  the  accompanying  tuberculous  nephritis. 

Diagnosis  is  based  upon  finding  the  tubercle  bacilli,  often  a  difficult 
matter,  elimination  of  other  causes,  and  cystoscopic  examination. 
This  may  show  disseminated  or  grouped  tubercles  or  ragged,  irregular 
punched-out  ulcers.  Usually  in  the  trigonum  in  the  neighborhood  of 
the  ureter.  Characteristic  family  history  and  tuberculous  involvement 
elsewhere  are  suggestive  evidence. 

In  the  absence  of  direct  bladder  examination,  apparently  causeless 
and  persistent  bladder  irritability  or  cystitis  is  in  itself  strongly  suggestive. 

Tumors  of  the  Bladder, — ^Tumors  of  the  bladder,  usually  observed 
in  middle-aged  men,  may  be  benign  or  malignant. 

Benign  tumors  are  usually  papillomata.  Next  in  order  of  frequency 
come  the  myxomata,  or  polypi.  Adenomata,  fibromata,  and  cysts  are 
reported. 

The  malignant  growths  include  sarcomata,  carcinomata,  and  mixed 
tumors. 

Carcinoma. — Carcinoma  is  the  commonest  of  all  bladder  tumors, 
including  both  the  benign  and  malignant.  The  tumor  is  usually  placed 
in  or  about  the  trigonum,  though  it  may  be  found  in  any  portion  of  the 
bladder  surface.  Sometimes  it  is  pedunculated,  usually  sessile,  and  is 
infiltrating. 

The  characteristic  symptom  is  sudden,  causeless,  profuse  hemorrhage 
stopping  as  quickly  as  it  started.     If  the  last  part  of  the  urine  passed 
contains  more  blood  than  the  first  part,  and  if  instrumental  examination 
of  the  bladder  always  occasions  free  bleeding  and  demonstrates  that  the 
tip  of  the  instrument  is  arrested  at  some  point  in  its  sweep,  the  diagnosis 


THE   URETERS  679 

of  vesical  tumor  is  well  assured.  Absolutely  so  if  with  the  blood  clots 
fragments  of  the  growth  of  suflScient  size  for  microscopic  examination 
are  passed.  Pain,  frequency,  and  urgency  are  usually  not  noted  until 
the  bladder  tumor  is  complicated  by  cystitis,  and  are  then  symptoms 
of  the  latter  condition  and  not  of  the  tumor. 

If  a  cystoscope  can  be  passed  without  occasioning  obscuring  bleeding, 
it  will  usually  afford  a  view  of  the  lesion  sufficiently  clear  to  be  diagnostic 
both  as  to  nature  and  position. 

A  recurring  vesical  bleeding  so  free  and  so  easily  excited  as  to  prevent 
the  use  of  the  cystoscope  calls  for  diagnosis  by  suprapubic  cystotomy, 
since  the  only  hope  of  cure  lies  in  early  operation.  The  passage  of 
irregularly  shaped  clots,  superabundance  of  bladder  epithelial  cells, 
absence  of  fragmentation  in  the  blood  corpuscles,  and  absence  of  kidney 
albumin  are  all  indicative  of  the  vesical  origin  of  hemorrhage.  The 
most  severe  and  frequently  recurring  hemorrhage  may  come  from  a 
small  papilloma. 

Benign  tumors  untreated  may  lead  to  a  fatal  termination,  either  from 
an  exhausting  hemorrhage  or  ascending  pyelonephritis.  The  course  of 
these  cases  is  extremely  slow  (many  years). 

Malignant  tumors  are  also  slow  (years)  both  in  growth  and  metastasis. 


THE  URETERS. 

The  ureters  are  musculomucous  canals  about  twelve  inches  long,  passing 
behind  the  peritoneum  from  the  renal  pelvis  to  the  bladder.  The  normal 
points  of  narrowing  are  about  two  inches  below  the  pelvis  of  the  kidney, 
at  the  crossing  of  the  iliac  artery  and  near  the  vesical  orifice.  The  ureters 
are  capable  of  enormous  dilatation  as  the  result  of  chronic  blocking. 
Even  though  not  dilated,  they  can  be  stretched  to  16  F.  without  tearing. 
The  vesical  portion  of  the  ureter  runs  obliquely  inward  and  forward  for 
half  an  inch  through  the  muscular  layer  of  the  bladder  wall,  opening  by 
a  slit-like  orifice,  the  upper  wall  of  which  is  devoid  of  muscular  fibers, 
and  so  thin  that  intravesical  tension  produces  a  valvular  closure. 

Anomalies  of  the  Ureter. — These  channels  may  be  absent  or  multiple; 
in  the  latter  case  either  fusing  or  passing  separately  into  the  bladder. 
The  double  ureter  is  commonly  associated  with  a  kidney  with  two  pelves. 
The  ureters  may  pursue  an  aberrant  course,  opening  at  the  external 
urinary  meatus  into  the  vagina  or  at  the  umbilicus. 

Valve  formation  is  a  common  cause  of  hydronephrosis.  The  ureter 
may  pass  from  the  pelvis  of  the  kidney  at  an  acute  angle  or  may  run  for 
some  distance  in  the  wall  of  this  reservoir  in  place  of  escaping  from  the 
funnel-shaped  orifice  at  its  lowest  portion. 

Rupture  of  the  ureter  is  characterized  by  extravasation  of  urine.  If  the 
urine  is  sterile,  this  need  not  lead  to  cellulitis.  Small  effusions  will  be 
absorbed.  If  the  extravasation  be  continuous,  a  large  fluctuating  tumor 
may  develop.  Rupture  of  the  ureter  is  ultimately  followed  by  stricture 
and  hydronephrosis. 


680  THE  GENITO-URINARY  ORGANS 

The  diagnosis  is  made  by  the  history  of  trauma  of  such  nature  as  to 
expose  the  ureter  to  injury,  followed  by  the  formation  of  a  fluctuating 
tumor  in  the  lumbar  region  unattended  with  the  symptoms  of  internal 
hemorrhage.  If  this  on  aspiration  is  found  to  be  urine  the  diagnosis  is 
assured.  When  the  rupture  is  not  sufficiently  extensive  to  cause  a 
demonstrable  urinary  extravasation  the  later  development  of  a  hydro- 
nephrosis will  prove  the  existence  of  a  previous  ureteral  injury. 

Wound  of  the  Ureter. — Wound  of  the  ureter  during  a  surgical  operation 
is  usually  recognized  both  by  the  escape  of  urine  and  because  the  thick- 
walled  white  cord  is  readily  recognized.  Ligation  of  the  ureter  is  fol- 
lowed in  rare  instances  by  signs  of  mild  renal  colic.  As  a  rule,  symptoms 
are  wanting  unless  both  ureters  are  ligated,  in  which  case  there  is 
anuria  Diagnosis  in  any  suspected  case  is  made  by  the  cystoscope 
failing  to  show  escape  of  urine  from  the  ureteral  orifice  and  by  the 
ureteral  catheter  encountering  the  obstruction. 

Ureteritis,  predisposed  to  by  congestion,  such  as  would  be  caused  by 
traumatism,  lodgement  or  passage  of  a  calculus  or  clot,  the  passage  of 
irritating  urine  or  distention  from  any  obstruction,  is  caused  by  infection 
which  may  ascend  from  the  bladder  or  descend  from  the  kidney.  Excep- 
tionally it  comes  from  without,  as  in  the  case  of  an  inflamed  appendix 
adherent  to  the  peritoneum  overlying  the  ureter.  The  symptoms  are 
indefinite,  and  are  usually  obscured  by  the  accompanying  pyelitis  or 
cystitis. 

The  diagnosis  may  be  suggested  by  urethral  tenderness  on  palpation. 
This  tenderness  will  be  found  by  making  deep  pressure  at  the  point  of 
intersection  of  a  line  joining  the  anterior  superior  iliac  spines  with  a 
vertical  line  running  upward  from  the  junction  of  the  inner  and  middle 
thirds  of  Poupart's  ligament.  Such  tenderness  is  not,  however,  pathog- 
nomonic of  ureteritis. 

Stricture  of  the  ureter  may  be  congenital  or  acquired.  The  symptoms 
are  those  of  back  pressure,  i.  e.,  hydronephrosis  and  dilatation  of  the 
ureter  above  the  seat  of  narrowing. 

The  diagnosis  may  be  made  by  ureteral  catheterization,  a  point  of 
narrowing  being  found  which,  after  having  been  passed  by  the  ureteral 
catheter,  will  yield  a  free  flow  of  urine. 

The  presence  of  hydronephrosis  not  due  to  stone,  movable  kidney,  or 
the  pressure  of  a  pelvic  tumor,  or  to  chronically  distended  bladder,  is 
suggestive  of  ureteral  stricture. 

Calculus  of  the  Ureter. — The  majority  of  calculi,  having  once  entered 
the  ureter,  pass  into  the  bladder  without  symptoms.  When  the  stone  is 
of  such  size  or  shape  that  it  cannot  immediately  pass,  it  is  arrested  at 
one  of  the  points  of  narrowing,  usually  just  above  the  bladder  or  in 
the  intravesical  portion  of  the  ureter. 

Ureteral  calculus  is  usually  single,  at  times  multiple,  exceptionally 
bilateral.  The  immediate  symptoms  of  an  arrested  or  slowly  progressing 
ureteral  calculus  are  those  of  renal  colic.  The  remote  symptoms,  if  the 
arrest  be  continuous,  are  hydro-  or  pyonephrosis.  Exceptionally  hydro- 
nephrosis incident  to  renal  calculus  develops  without  history  of  preceding 


THE   URETERS  681 

acute  pain.  During  the  attack  of  colic  the  urine  will  contain  no  blood 
unless  the  obstruction  is  incomplete.  With  the  subsidence  of  severe 
pain  blood  appears  in  the  urine,  often  only  microscopically. 

Typical  renal  colic,  which  will  be  caused  by  any  sudden  ureteral  obstruc- 
tion and  consequent  renal  tension,  is  characterized  by  the  sudden  onset 
of  agonizing  pain,  located  in  the  lumbar  and  hypochondriac  regions  and 
radiating  therefrom  along  the  course  of  the  ureter,  to  the  end  of  the  penis, 
to  the  testicle  of  the  affected  side,  to  the  inner  surface  of  the  thigh.  The 
pain  is  sufficiently  severe  to  cause  marked  shock,  at  times  collapse.  It 
is  attended  with  abdominal  tympany,  vomiting,  and  tenderness,  urgent 
desire  to  micturate,  with  loss  of  power  to  do  so,  and  tenderness,  elicited 
by  deep  pressure  in  the  angle  made  by  the  last  rib  and  the  erector  spinse 
muscles,  or  from  before  backward  just  below  the  tenth  costochondral 
junction. 

Exceptionally  the  pain  may  radiate  to  the  chest  or  shoulders  or  be 
referred  to  the  unaffected  kidney. 

The  distinction  from  acute  fulminating  peritonitis  must  be  made  by 
the  absence  of  rigidity,  the  seat  of  tenderness  on  pressure,  the  finding 
of  blood  in  the  urine,  radiations  of  pain  to  the  penis  and  testicle,  and 
interference  with  bladder  function  when  the  stone  is  lodged  in  the  pelvic 
portion  of  the  ureter. 

When  anuria  develops,  this  is  evidence  of  bilateral  renal  disease, 
probably  but  not  necessarily  calculous. 

After  the  subsidence  of  an  acute  renal  colic,  or  in  the  absence  of  this, 
a  stone  lodged  in  the  intravesical  portion  of  the  ureter  will  cause  frequent, 
urgent,  painful  micturition  and  usually  pus  in  the  urine,  i.  e.,  the  symp- 
toms of  posterior  urethritis. 

The  diagnosis,  unless  it  be  suggested  by  a  history  of  repeated  renal  colics 
followed  by  the  development  of  a  hydronephrosis  or  pyonephrosis,  must 
be  made  by  cystoscopic  examination,  showing  an  inflamed  patulous 
ureteral  opening  from  which  the  stone  may  project  as  a  tumor.  Ureteral 
sounding  will  demonstrate  the  presence  of  obstruction,  and,  if  a  bougie 
with  a  wax  end  should  be  used,  it  will  possibly  show  markings  incident 
to  impact  against  the  calculus. 

The  x-rays,  on  which  from  a  diagnostic  standpoint  the  main  reliance 
must  often  be  placed,  may  be  misleading,  since  phleboliths  and  caseating 
glands  give  pictures  much  like  those  of  ureteral  stone.  Multiple  shadows 
should  always  be  distrusted,  and  this  is  particularly  so  if  they  are  not 
placed  strictly  in  the  line  of  the  ureter  or  if  the  patient  examined  be 
suffering  from  genito-urinary  tuberculosis. 

The  persistent  lodgement  of  a  stone  in  the  ureter  or  the  pelvis  of  the 
kidney,  unattended  with  hydronephrosis  or  pyelonephrosis  of  such  extent 
as  to  be  palpable,  has  been  mistaken  for  chronic  appendicitis  and 
cholecystitis. 

The  presence  of  blood  and  pus  in  the  urine  and  the  downward  radia- 
tions of  pain  during  the  acute  attacks  are  characteristic. 

Ureteral  fistulse  are  characterized  by  a  steady  or  irregular  flow  of 
urine.     They  are  kept  up  by  stricture  and  show  little  tendency  toward 


682  THE  GENITO-URINARY  ORGANS 

spontaneous  cure.  Cystoscopic  examination  and  ureteral  catheterization 
may  be  needful  to  exclude  the  vesical  origin  of  such  fistulse. 

Tuberculosis  of  the  ureter  can  be  diagnosticated  only  by  the  develop- 
ment of  obstructive  symptoms.  It  is  masked  by  the  associated  tubercu- 
losis of  the  bladder  and  kidney. 

The  ureteral  papilla  is  the  most  frequent  seat  of  cancer.  This  can 
be  diagnosticated  only  by  cystoscopic  examination.  The  first  symptom 
of  growths  situated  elsewhere  in  the  ureter  would  probably  be  those 
of  obstruction,  though  unusually  free  bleeding  from  the  passage  of  a 
ureteral  instrument  might  suggest  papilloma. 


THE  KIDNEYS. 

The  kidneys  are  placed  in  the  upper  back  part  of  the  abdomen,  behind 
the  peritoneum,  and,  if  normal  in  size  and  position,  cannot  be  felt.  In 
people  of  relaxed  fiber,  particularly  women  who  have  lost  much  fat,  the 
right  kidney  is,  as  a  rule,  distinctly  palpable  on  deep  expiration. 

The  lower  poles  of  both  kidneys  lie  above  the  umbilicus.  A  vertical 
line  carried  up  from  the  middle  of  Poupart's  ligament  to  the  costal  arch 
should  cross  the  kidney  at  about  the  junction  of  the  middle  and  inner 
thirds. 

Surgical  diseases  of  the  kidney  are  characterized  by  displacement,  pain, 
tumor,  pus,  blood,  and  renal  elements  in  the  urine,  lessened  permea- 
bility, and  the  systemic  manifestations  of  toxemia  or  infection. 

The  simplest  and  most  satisfactory  proof  of  renal  permeability  is  the 
passage  of  an  adequate  quantity  of  urine  containing  a  normal  percentage 
of  urea. 

Since  surgical  intervention  is  usually  directed  to  one  kidney,  it  is  of 
cardinal  importance  if  the  nature  of  the  malady  be  such  as  to  require 
nephrectomy  (malignant  growth,  tuberculosis,  pyonephrosis),  that  there 
be  a  functionally  competent  kidney  on  the  other  side. 

The  existence  of  two  kidneys  may  be  determined  by  x-rays,  and 
almost  certainly,  except  when  the  kidneys  are  fused,  by  ureteral  cath- 
eterization. 

Permeability,  i.  e.,  functional  activity  of  each  organ,  can  be  absolutely 
assured  only  by  ureteral  catheterization  and  examination  of  the  secre- 
tion thus  obtained  from  each  kidney.  When  one  kidney  is  obviously 
extensively  diseased  and  renal  excretion  is  satisfactorily  maintained, 
it  is  probable  that  the  remaining  and  apparently  healthy  kidney  is 
adequate  to  its  function. 

The  phloridzin  test  is  based  upon  the  power  of  the  normal  kidney 
to  eliminate  sugar  within  a  certain  time  after  the  subcutaneous  adminis- 
tration of  phloridzin.  In  renal  disease  the  appearance  of  sugar  in  the 
urine  is  delayed  and  the  elimination  is  feeble,  prolonged,  or  absent. 

Cryoscopy,  or  determination  of  the  freezing  point  of  the  urine,  is  an 
elaborate  procedure,  requiring  from  10  to  20  c.c.  of  this  fluid.  Its 
compensating  value  is  questionable. 


THE  KIDNEYS  683 

The  passage  of  the  ureteral  catheter  will  sometimes  inhibit  the  flow  of 
urine  for  from  ten  to  thirty  minutes. 

Anomalies. — ^The  kidneys  may  depart  from  the  normal  in  number, 
shape,  size,  position,  attachment,  and  mobility. 

The  absence  of  one  kidney  has  been  noted  with  sufficient  frequency 
to  warrant  the  surgeon  in  assuring  himself  of  the  presence  of  both  kidneys 
before  performing  nephrectomy.  This  defect  is  more  common  on  the 
left  than  on  the  right  side.  A  single  kidney  is  large.  Fused  kidney  may 
assume  the  shape  of  a  horseshoe  or  may  be  fused  along  the  whole  inner 
surface,  forming  one  large  oval  or  rounded  organ,  with  bloodvessels  and 
excretory  ducts  attached  to  its  centre  or  possibly  to  one  side.  It  may 
reach  enormous  size,  simulating  abdominal  tumor. 

The  kidney  may  be  displaced  from  its  normal  position  in  any  direction 
except  posteriorly.  The  displacement  is  usually  downward,  the  kidney 
lying  in  the  region  of  the  sacroiliac  articulation.  It  may  be  tilted, 
rotated,  or  turned  on  its  own  axis. 

A  displaced  kidney,  often  fixed  in  its  false  position,  usually  causes  no 
symptom. 

Floating  kidney  is  a  congenital  anomaly  in  which  the  organ  is  loosely 
attached  to  the  posterior  abdominal  wall  by  a  mesonephron.  The 
diagnosis  can  be  suspected  from  the  free  mobility,  but  can  be  assured 
only  by  operation. 

Movable  Kidney. — The  kidney  is  normally  movable,  falling  and  rising 
with  each  respiratory  act. 

It  may  be  capable  of  excursions  much  greater  than  those  recognized 
as  normal  or  may  lie  permanently  below  its  proper  level  without  exhibit- 
ing symptoms.  This  condition  is  common  in  thin,  long-bodied  neuras- 
thenic women  with  an  obsession  for  doctors. 

Movable  kidney,  when  it  becomes  a  surgical  affection,  is  characterized 
by  renal  colic  sudden  in  onset,  recurrent,  with  associated  gastro-intestinal 
symptoms.  This  colic  is  sometimes  relieved  by  position,  is  associated 
with  albumin,  hyaline  casts,  and  sometimes  blood  in  the  urine,  with 
palpable  tenderness  of  the  kidneys,  and  is  followed  by  hypersecretion  of 
urine.  Hepatic  colic,  dilatation  of  the  stomach,  and  gastric  catarrh 
have  been  attributed  to  the  drag  of  the  right  kidney,  while  intestinal 
indigestion  has  been  attributed  to  movable  left  kidney  through  partial 
blocking  of  the  descending  colon. 

The  diagnosis  of  movable  kidney  is  made  by  direct  palpation.  The 
patient  is  placed  in  the  dorsal  decubitus,  with  the  thighs  flexed,  head  and 
shoulders  elevated,  and  the  trunk  slightly  inclined  toward  the  side  to  be 
examined  by  a  thin  pillow  placed  under  the  opposite  loin.  The  fingers 
of  one  hand  are  placed  posteriorly  just  below  the  twelfth  rib,  those  of  the 
other  hand  in  front  below  the  costal  margin,  over  the  lower  pole  of  the 
kidney.  The  patient  is  directed  to  breathe  deeply.  By  gradually 
increasing  the  bimanual  pressure  the  examining  fingers  are  sunk  deeply 
down  until  the  kidney  is  felt  in  -its  inspiratory  descent.  In  women, 
particularly  those  who  are  emaciated,  the  normal  kidney  can  often  be 
felt  on  the  right  side.     Wlien,  however,  the  kidney  descends  so  far  during 


684  THE  GENITO-URINARY  ORGANS 

inspiration  that  its  expiratory  ascent  can  be  prevented  by  firmly  pressing 
above  it  with  the  examining  fingers,  the  mobihty  is  abnormal.  The 
gravity  of  the  affection,  however,  is  dependent,  not  upon  the  freedom 
of  mobility,  but  upon  the  presence  of  symptoms  produced  by  it. 

In  distinguishing  the  kidney  from  other  tumors  its  characteristic  shape 
and  the  completeness  with  which  it  can  be  pressed  back  into  the  normal 
position  are  highly  characteristic. 

From  omental  growths  and  tumors  of  the  colon,  movable  kidney  can 
be  distinguished  by  the  fact  that  it  lies  behind  these. 

Dilatation  of  the  gall-bladder  presents  the  greatest  diagnostic  difficulty. 
The  tumor  is,  however,  obviously  anterior  and  continuous  with  the 
liver,  cannot  be  made  to  recede  into  the  loin,  and,  if  subject  to  attacks  of 
colic,  is  tender  to  superficial  anterior  pressure  and  does  not  give  down- 
ward pain  radiation  attended  or  followed  by  blood  in  the  urine.  Nor 
can  it  be  made  distinctly  more  prominent  and  accessible  by  pressure  in 
the  loin.  When  palpation  leaves  the  examiner  in  doubt,  the  affection  is 
usually  one  of  the  kidney. 

Contusion  of  the  Kidney. — Contusion  of  the  kidney  may  be  caused  by 
direct  or  indirect  violence,  as  from  kicks,  blows,  pressure  or  contortion, 
flexions  of  the  trunk,  or  by  violent  jarring  from  a  fall. 

Direct  violence  is  usually  inflicted  by  a  narrow  vulnerating  body,  since 
the  kidney  is  protected  against  broad  pressure.  The  lesion,  usually 
complicated  by  trauma  of  neighboring  organs,  varies  from  subcapsular 
ecchymoses  and  intrarenal  blood  extravasation  to  extensive  rupture. 
Intrarenal  bleeding  is  rarely  profuse.  Extrarenal  hemorrhage  may  be  fatal. 
The  symptoms  are  hematuria,  and  usually  shock  and  severe  sickening 
pain,  followed  by  the  formation  of  lumbar  tumor  if  there  be  extrarenal 
bleeding. 

Hematuria  may  be  absent  if  the  ureter  be  ruptured,  slight  if  the  hemor- 
rhage be  mainly  extracapsular  or  parenchymatous,  or  profuse.  Hemor- 
rhage so  severe  as  to  threaten  life  is  usually  intraperitoneal  or  perinephric. 
The  urine  often  contains  worm-like  clots  moulded  into  this  shape  by  the 
ureter,  and,  because  of  the  blocking  caused  by  these  clots,  attacks  of  renal 
colic  may  supervene.     Recurrent  hemorrhage  is  not  uncommon. 

The  characteristic  sickening  renal  pain  is  more  marked  in  contusions 
characterized  by  slight  ecchymosis  than  in  extensive  lacerations,  nor  is 
immediate  shock  a  reliable  index  as  to  the  extent  of  renal  lesion. 

Lumbar  tumor  developing  in  a  few  hours  is  due  to  blood.  If  it  in- 
creases from  day  to  day  without  inflammatory  symptoms  other  than  those 
normal  to  a  clean  wound  reaction,  it  is  probably  due  to  urine  which  may 
be  retained  in  the  renal  pelvis  or  may  be  extravasated  into  the  perirenal 
tissue,  forming  a  false  hydronephrosis. 

Renal  Calculus. — Renal  calculus  may  be  single  or  multiple.  It  is 
usually  irregular  in  shape  and  of  uric  acid.  Next  in  order  of  frequency 
are  the  oxalates.  Both  these  stones  are  deposited  from  acid  urine. 
Calculi  made  up  of  phosphate  or  carbonate  of  lime  are  deposited  from 
alkaline,  usually  infected,  urine. 

Calculus  is  usually  found  in  the  renal  pelvis  or  its  branches.      Excep- 


THE  KIDNEYS  685 

tionally  it  is  placed  in  the  substance  of  the  kidney.  In  the  absence  of 
infection  the  calcukis  is  generally  adherent,  taking  the  shape  of  the  por- 
tion of  the  pelvis  in  which  it  is  placed;  at  times  bifurcating  or  branching 
like  a  piece  of  coral,  representing  a  mould  of  the  pelvis  and  its  subdivi- 
sions.    In  about  15  per  cent,  of  cases  both  kidneys  are  affected. 

The  uric  acid,  the  oxalate  or  th"e  phosphatic  diathesis  and  local  infection 
are  predisposing  factors.  They  favor  coagulation  necrosis  of  cells,  thus 
furnishing  the  organic  framework  essential  to  calculus  formation. 

The  affection  may  be  without  symptoms.  Usually  it  is  characterized 
by  pain  in  the  back  just  below  the  twelfth  rib  and  in  front  over  the  posi- 
tion of  the  kidney,  attacks  of  renal  colic,  renal  tenderness,  testicular 
or  ovarian  hyperesthesia  of  the  affected  side  (Bittorf),  hematuria,  renal 
albumin,  hyaline  casts,  and  gastro-enteric  disturbances. 

The  characteristic  pain  is  an  ache,  aggravated  by  bodily  activity  and 
repeated  jarring.  Subject  to  acute  exacerbations,  which  may  occur  at 
night,  waking  the  patient.  These  exacerbations  may  take  the  form  of 
acute  renal  colic  attended  by  vomiting,  tympany,  and  collapse,  exhibiting 
downward  radiations  along  the  course  of  the  ureter  and  into  the  genitals. 
Exceptionally  the  pain  is  referred  to  the  healthy  kidney. 

During  the  periods  of  exacerbation,  often  at  all  times,  there  is  renal 
tenderness  elicited  by  deep  palpation. 

Hematuria  is  usually  detected  only  on  microscopic  examination,  is 
intermittent,  and  is  markedly  increased  by  jarring  or  bodily  activity. 
Exceptionally  it  is  transitorily  profuse,  apparently  causeless,  and  is  sub- 
ject to  recurrence  at  long  intervals.  Frequent  urination  is  a  common 
reflex,  though  it  is  more  essentially  a  symptom  of  calculus  lodged  in 
the  ureter.  Passage  of  gravel  or  fragments  of  calculi  are  symptoms  of 
great  diagnostic  value. 

Temporary  suppression  of  urine  may  occur  during  attacks  of  renal 
colic.  This,  when  it  persists  for  several  days,  is  indicative  of  bilateral 
disease. 

The  gastro-intestinal  disturbances,  i.  e.,  distaste  for  food,  tardy  stomach 
digestion,  flatulence,  constipation,  and  diarrhea,  may  be  reflex.  They 
are  usually,  however,  expressions  of  toxic  absorption. 

When  stone  in  the  kidney  becomes  complicated  by  infection,  this  is 
indicated  by  pus  in  the  urine  and  marked  aggravation  of  all  the  symp- 
toms, especially  those  of  gastro-intestinal  disturbance.  Pyelitis  is  sug- 
gestive of  stone  simply  because  it  is  such  a  common  sequel  of  this 
condition. 

Of  these  symptoms,  pain  and  hematuria  are  the  two  most  constant  and, 
with  the  exception  of  the  passage  of  calculus  fragments,  the  most  char- 
acteristic. 

The  absolute  diagnosis  is  made  by  the  a^-rays,  or,  this  failing,  by 
exploratory  incision. 

The  .T-rays  afford  the  most  trustworthy  means  of  making  the  diagnosis. 
The  picture  must  be  clear  and  unmistakable,  and  repetitions  must  show 
a  correspondence  in  the  shadow  or  shadows  in  at  least  two  pictures 
taken  at  different  times.     In  the  case  of  uric  acid  calculi  the  x-rays  may 


686  THE  GENITO-URINARY  ORGANS 

fail.  Hence,  if  symptoms  are  persistent,  with  signs  of  progressing  renal 
degeneration  or  infection,  the  diagnosis  must  be  made  by  direct  incision. 

The  symptoms  of  renal  calculus  may  be  closely  simulated  by  neph- 
ralgia, crises  of  locomotor  ataxia,  oxaluria,  phosphaturia,  chronic 
interstitial  nephritis  or  tuberculosis  of  the  kidney,  movable  kidney, 
cholecystitis,  or  appendicitis. 

Nephralgia,  oxaluria,  phosphaturia,  and  strongly  acid  urine  may  all 
be  characterized  by  renal  tenderness,  blood  in  the  urine,  and  pain  with 
paroxysmal  exacerbations  radiating  downward.  Nephralgia  occurs  in 
neurasthenic  females,  is  worse  at  the  time  of  the  catamenia,  is  charac- 
terized by  the  passage  of  large  quantities  of  urine  of  low  specific  gravity, 
and  very  exceptionally  the  urine  contains  a  few  blood  corpuscles. 

The  dull  pain  and  slight  hematuria  of  oxaluria  or  phosphaturia  are 
transitory  in  nature,  and  disappear  completely  under  appropriate  treat- 
ment.    These  conditions  are,  however,  often  associated  with  calculus. 

Crises  of  locomotor  ataxia,  which  may  exactly  simulate  renal  colic,  are 
suggested  by  the  history  of  the  case  and  other  symptoms  of  cord  degenera- 
tion, nor  is  there  blood  found  in  the  urine  either  during  or  after  the  attack. 

Tuberculosis  may  exhibit  precisely  the  symptoms  of  stone.  The 
finding  of  the  tubercle  bacillus  will  be  diagnostic.  It  ultimately 
becomes  complicated  by  tuberculosis  of  the  bladder,  but  the  diagnosis 
should  be  formed  before  this  develops.  Tuberculous  lesions  elsewhere 
would  be  suggestive.  Mixed  infection  develops  earlier  than  is  the  case 
with  calculus,  hence  an  apparently  causeless  pyelitis  in  the  absence  of 
preceding  symptoms  of  long  standing  (months  or  years)  is  suggestive 
of  renal  tuberculosis. 

Movable  kidney  must  be  distinguished  by  the  detection  of  this  condition 
by  direct  examination.  Aside  from  the  mobility  the  symptoms  may  be 
identical. 

Gallstone  colic  gives  upward  and  backward  radiation.  Tenderness 
is  marked  on  superficial  pressure  over  the  region  of  the  gall-bladder, 
there  is  an  abundant  secretion  of  urine  not  containing  blood  and  there 
is  no  difficulty  in  passing  urine.  The  preceding  history  is  often  char- 
acteristic. 

Appendicitis  may  simulate  renal  colic.  In  the  acute  attack  the 
location  of  the  point  of  greatest  tenderness  is  characteristic  and  mus- 
cular rigidity  is  not  found  in  renal  colic,  though  this  may  be  simulated 
by  the  voluntary  resistance  of  the  patient  during  examination.  If  the 
appendix  be  adherent  to  the  ureter  or  point  downward,  involving  the 
bladder,  the  vesical  symptoms  may  exactly  simulate  those  of  renal  or 
ureteral  irritation.  The  blood  will,  however,  be  absent  from  the  urine. 
Nor  can  renal  tenderness  be  elicited  by  deep  dorsal  pressure  beneath 
the  last  rib. 

The  distinction  between  ureteral  and  renal  calculus  may  be  suggested 
by  tenderness  along  the  course  of  the  ureter  and  marked  vesical  symp- 
toms. It  can  be  made  positively  only  by  the  a;-rays  and  by  exploration  of 
the  ureter  at  the  time  of  operation.  This  should  always  be  done  when  the 
kidney  is  opened,  particularly  if  the  ureter  is  dilated. 


THE  KIDNEYS  687 

Suppurative  Diseases  of  the  Kidney.  ^ — Predisposition  is  offered  by 
renal  congestion,  the  ordinary  cause  of  which  is  back  pressure  from 
obstruction  in  any  part  of  the  urinary  tract.  Exposure  to  cold;  trauma- 
tism; drug  irritation,  such  as  that  incident  to  irritating  diuretics,  anti- 
septics, balsams,  and  ethereal  oils;  chronic  interstitial  nephritis;  gastro- 
enteritis; gout;  pregnancy;  the  mechanical  irritation  of  gravel  or  calculus; 
irritation  of  elimination  in  acute  infectious  diseases,  and  tuberculosis 
are  common  predisposing  factors  to  infection. 

The  usual  microorganisms  of  renal  suppuration  are  the  Bacterium 
coli  communis,  the  Staphylococcus  aureus,  the  Streptococcus  pyogenes, 
and  the  Proteus  hauseri.  Exceptionally  the  gonococcus,  the  typhoid 
bacillus,  the  pneumonia  diplococcus  are  the  caustive  agents. 

Infection  may  reach  the  kidney  through  the  blood  in  the  course  of 
elimination.  This  is  the  common  route  when  suppurative  inflammation 
occurs  in  the  course  of  infective  fever.  It  may  extend  to  the  kidney  from 
inflammation  of  adjacent  structures.  It  is  usually  secondary  to  infec- 
tion of  the  bladder,  ascending  by  way  of  the  ureter. 

The  infection  may  take  the  form  of  a  pyelitis,  which,  if  complicated 
by  obstruction,  becomes  a  pyelonephrosis,  the  inflammation  reaching 
its  maximum  in  the  pelvis  of  the  kidney.  When  both  the  pelvis  and 
the  renal  parenchyma  are  extensively  involved  the  affection  is  called 
pyelonephritis.  This  is  the  form  usually  taken  by  an  ascending 
infection.  Suppuration  of  the  renal  substance  secondary  to  systemic 
infection,  and  entering  by  the  blood  channnels,  may  be  without  char- 
acteristic symptoms  until  the  rupture  of  an  abscess  into  the  renal  pelvis 
or  the  perirenal  tissue  causes  a  sudden  pyuria  or  a  perinephric  abscess. 

The  characteristic  symptoms  of  renal  infection  are  pain  in  the  lumbo- 
dorsal  region,  fever  which  may  be  exceedingly  high  and  accompanied 
by  chills  and  sweats,  renal  tenderness  on  deep  palpation,  and  pus  of  renal 
origin  in  the  urine.  This  point  may  be  determined  by  ureteral  catheter- 
ization or  inspection  of  the  urinary  jet  as  it  escapes  from  the  ureter. 

Pyelitis. — Usually  bilateral,  it  is  even  in  its  acute  outbreak  often 
obscured  by  the  symptoms  of  an  antecedent  disease,  such  as  gastro- 
enteritis, typhoid,  pneumonia,  or  la  grippe  infections,  or  by  those  of 
acute  or  chronic  cystitis. 

In  its  acute  form  it  is  characterized  by  severe  pain  in  the  region  of  the 
kidney,  tenderness  on  palpation,  frequent  urination,  with  decrease  in  the 
total  quantity,  and  often  vomiting,  fever,  chills,  and  sweat.  The  urine  is 
usually  acid,  contains  a  trace  of  albumin,  degenerated  epithelium,  hyaline 
casts,  mucus,  pus,  and  often  blood. 

Chronic  pyelitis  may  be  attended  with  no  symptoms  other  than  pus  in 
the  urine  and  is  often  overlooked,  particularly  in  children.  Diagnosis 
depends  upon  the  examination  of  the  urine  secured  by  ureteral  catheteriza- 
tion. Usually  there  is  kidney  ache,  some  slight  local  tenderness  on  deep 
pressure,  and  general  impairment  of  health  and  slight  toxic  anemia. 
The  urine,  usually  acid,  contains  polynuclear  leukocytes,  nucleo-albumin 
(from  the  pus  and  blood),  and  is  increased  in  amount.  The  casts  are  of 
the  hyaline  variety.     There  are  frequently  recurring  subacute  attacks. 


THE  GENITO-URINARY  ORGANS 

Intermittent  pyuria,  i.  e.,  pus  disappearing  from  the  urine  for  some 
hours  and  then  recurring,  shows  that  the  inflammation  is  confined  to  one 
side,  and  that  pyonephrosis  is  developing  on  that  side. 

In  the  absence  of  acute  obstruction  and  its  attendant  renal  colic,  poly- 
uria and  pyuria  are  the  most  diagnostic  features.  Nocturnal  frequency 
is  regarded  by  Bazy  as  highly  characteristic. 

Pyonephrosis.- — Pyonephrosis  is  a  sequel  of  pyelitis  and  backpressure, 
or  is  caused  by  infection  of  a  hydronephrosis.  In  the  former  case  there 
is  usually  a  history  of  renal  infection  associated  with  recurring  attacks 
of  renal  colic,  often  the  presence  of  a  palpable,  tender  tumor,  with  the 
fever  and  sweats  of  either  acute  or  chronic  sepsis. 

The  tumor,  if  present,  lies  behind  the  colon,  can  be  felt  by  bimanual 
palpation,  is  freely  movable,  but  slightly  tender,  except  during  attacks  of 
colic,  exceptionally  distinctly  fluctuating,  and  varies  in  size  from  time  to 
time.  This,  together  with  intermittent  pyuria,  or,  more  commonly, 
marked  variations  in  the  quantity  of  pus,  is  a  highly  characteristic 
feature. 

Exceptionally  a  pyonephrosis  develops  with  almost  no  symptoms 
other  than  those  of  impaired  health  and  toxic  anemia.  The  dis- 
tinction from  hydronephrosis  is  made  by  urinary  examination  and  by 
the  absence  of  constitutional  symptoms  in  cases  of  simple  urinary 
retention. 

Pyelonephritis. — Pyelonephritis  is  the  usual  sequel  of  pyonephrosis, 
the  suppuration  involving  and  destroying  the  kidney  parenchyma. 
The  acute  form  of  infection  is  characterized  by  lumbar  pain  and  violent 
septic  symptoms,  i.e.,  prolonged  chills,  high  fever,  and  drenching  sweats, 
associated  with  an  irritable  condition  of  the  stomach,  characterized  by 
persistent  vomiting  and  hiccough.  The  associated  symptoms  of  intoxica- 
tion are  those  of  sepsis  and  uremia.  The  prognosis,  though  extremely 
bad,  is  not  absolutely  so,  there  being  a  possibility  of  the  pus  collections 
draining  through  the  ureter. 

Chronic  pyelonephritis  is  characterized  by  pus  in  the  urine,  and  a 
toxic  condition  exhibited  by  complete  anorexia,  dry  tongue,  scanty 
secretion  of  saliva,  tympany,  constipation,  often  uncontrollable  diarrhea. 
Intercurrent  acute  febrile  attacks  develop.  There  may  be  no  pain  or 
other  local  symptoms,  the  diagnosis  of  the  affection  being  entirely 
dependent  upon  the  examination  of  the  urine.  There  is  usually  polyuria, 
except  in  the  terminal  stage,  and  constant  pyuria  subject  to  marked 
quantitative  variations.  At  times  necrotic  fragments  of  renal  substance 
are  passed,  often  preceded  by  renal  colic  from  temporary  blocking  of  the 
ureter.  Frequently  repeated  severe  attacks  of  renal  colic  suggest  the 
complication  of  renal  calculus. 

The  distinction  between  cystitis  and  pyelonephritis  is  made  by  ureteral 
catheterization,  though  chronic  cystitis  produces  very  little  systemic 
effect. 

When  the  underlying  lesion  of  a  pyelonephritis  is  tuberculous,  this 
may  be  suggested  by  tuberculous  lesion  elsewhere.  If  the  bacillus 
canf  be  recovered  from  the  urine,  this  will  be  diagnostic.     Mere  per- 


THE  KIDNEYS  689 

sistence  of  the  infection  in  the  absence  of  obstruction  or  calculus  is 
strongly  suggestive. 

Acute  hematogenous  nephritis,  usually  unilateral,  is  characterized  by 
the  rapid  development  of  septic  symptoms.  Chills,  fever,  and  sweats, 
with  rapid  and  at  first  sthenic  pulse,  abdominal  tympany  and  tenderness, 
but  without  rigidity,  and  tenderness  on  deep  pressure  at  the  costo- 
vertebral angle.  The  urine  at  first  may  show  only  a  trace  of  albumin 
and  a  few  red  blood  cells.  Later,  if  the  patient  survives,  when  abscesses 
form  and  break  into  the  pelvis,  there  will  be  pus  in  quantity.  The 
swollen  kidney  can  sometimes  be  felt.  Early  diagnosis  is  based  upon 
violent  septic  symptoms  and  the  seat  of  local  tenderness.  Occurring  on 
the  right  side  the  affection  strongly  suggests  appendicitis. 

Perinephric  Suppuration. — Perinephric  suppuration,  which  may  be 
traumatic  in  origin  or  secondary  to  renal  suppuration  or  infection  of 
neighboring  organs,  particularly  the  appendix,  is  commonest  in  middle- 
aged  men. 

The  pus  usually  discharges  in  the  lumbar  region  or  passes  upward 
toward  the  pleural  cavity,  causing,  first,  a  serous  effusion,  later  an 
empyema.  It  may  burrow  into  the  pelvis  behind  the  peritoneum, 
may  pass  down  within  the  sheath  of  the  psoas  muscle,  or  may  rupture 
into  the  ureter,  kidney,  colon,  duodenum,  or  stomach. 

The  affection  is  characterized  by  pain,  tenderness,  and  fever,  and  a 
fixed,  vaguely  outlined,  rapidly  progressing  tumor  in  the  lumbar  region. 
When  the  affection  is  not  masked  by  a  preceding  causative  lesion,  such 
as  appendicitis,  pyelonephrosis,  or  himbar  osteomyelitis,  the  diagnosis 
is  readily  formulated.  The  pain  is  aggravated  by  motion  of  the  thigh 
of  the  affected  side  and  the  body  is  curved  toward  this  side.  The 
thigh  is  sometimes  flexed  and  adducted,  and  there  is  marked  poly- 
morphonuclear leukocytosis,  except  when  the  abscess  is  purely  tuber- 
culous secondary  to  bone  involvement.  Frequently  there  is  tympany 
and  vomiting. 

Spinal  tuberculosis  will  usually  be  noted  by  its  slow  onset  and  by 
associated  symptoms.  A  neoplasm  fixed  in  position  can  be  differentiated 
from  pure  perinephric  abscess  only  by  its  comparatively  slow  and 
progressive  growth  and  by  the  absence  of  septic  symptoms  and  pyuria. 

Hydronephrosis. — Hydronephrosis,  due  to  obstruction  to  the  flow  of 
urine  through  any  portion  of  the  urinary  tract,  may  be  congenital  or 
acquired.  It  may  be  persistent  or  intermittent,  unilateral  or  bilateral, 
partial  or  total.  Partial  hydronephrosis  involves  one  or  more  calices, 
but  not  the  whole  pelvis. 

Bilateral  hydronephrosis  is  incident  to  obstruction  low  down  in  the 
urinary  tract.  Enlarged  prostate,  hypertrophy  of  the  bladder  from 
urethral  obstruction,  and  tumors  of  the  pelvic  organs  compressing  the 
ureters  are  common  causes. 

The  usual  causes  of  unilateral  hydronephrosis  are  calculus  and  mov- 
able kidney.     Valve  formation  and  irregular  implantation  of  the  ureter 
into  the  renal  pelvis  are  unusual  causes.     Even  postmortem  examina- 
tion has  at  times  failed  to  detect  a  cause, 
44 


690  THE  GENITO-URINARY  ORGANS 

The  secreting  substance  of  the  kidney  ultimately  disappears  from 
pressure  atrophy  and  interstitial  nephritis  incident  to  interference 
with  the  circulation. 

The  diagnosis  of  hydronephrosis  is  based  upon  the  finding  of  a  smooth, 
rounded,  movable,  fluctuating  tumor  placed  behind  the  colon,  unat- 
tended with  fever,  pain,  or  tenderness. 

The  intermittent  form  of  the  disease  is  characterized  by  the  recurring 
development  of  a  tumor,  accompanied  usually  by  renal  colic  and  by  the 
rapid  diminution  in  size  or  disappearance  of  this  tumor  attended  with 
polyuria.  After  attacks  of  renal  colic,  the  urine  may  contain  blood, 
albumin,  and  hyaline  casts. 

When  the  hydronephrosis  is  well  developed  (containing  many  gallons), 
distinction  from  cystic  growths,  particularly  those  of  ovarian  origin, 
can  be  made  only  by  the  history  of  the  case.  The  presence  of  urinary 
salts  usually  proves  the  origin  of  the  fluid.  These  may  be  absent  when 
the  renal  parenchyma  has  atrophied. 

Tuberculosis  of  the  Kidney. — ^Tuberculosis  of  the  kidney  may  appear 
in  its  acute  form  as  a  part  of  general  miliary  tuberculosis.  The  symp- 
toms are  then  masked  by  the  general  systemic  invasion. 

Chronic  renal  tuberculosis  may  appear  as  the  sole  evidence  of  tuber- 
culous invasion,  or  may  be  secondary  to  lesions  of  the  lungs,  bones,  or 
other  parts  of  the  body.  It  is  commonest  in  early  manhood,  and  in 
its  beginning  is  unilateral.  The  second  kidney  is  ultimately  involved 
by  the  infection  which  first  invades  the  bladder,  then  blocks  the  ureter 
of  the  healthy  side,  and  finally  reaches  this  kidney  predisposed  to  infec- 
tion by  the  congestion  incident  to  blocking  and  prolonged  elimination 
of  toxic  substances. 

The  diagnosis  in  the  early  stage  of  the  affection  is  based  upon  a  con- 
stant or  intermitting  ache  in  the  renal  region,  deterioration  in  general 
health,  polyuria  and  frequent  urination  not  otherwise  explicable,  slight 
(usually  microscopic)  transitory,  apparently  causeless,  hematuria,  and 
demonstration  of  tubercle  bacilli  in  the  urine. 

The  existence  of  lesions  obviously  tuberculous  in  other  parts  of  the 
body,  particularly  in  the  genito-urinary  tract,  and  tuberculous  family 
history  are  sufficiently  common  to  be  of  diagnostic  value.  The  tuber- 
culin test  may  be  serviceable. 

When  the  disease  is  fairly  well  advanced  and  involves  the  pelvis  of 
the  kidney,  hyaline  and  granular  casts  appear  and  the  descending 
infection  involves  the  ureter,  the  renal  orifice  of  which  becomes  edema- 
tous, hyperemic,  and  sometimes  eroded. 

On  the  advent  of  mixed  infection,  which  develops  earlier  than  is  the 
case  with  stone,  the  symptoms  of  pyelitis  and  pyelonephritis  or  pyelo- 
nephrosis  develop.  This,  in  the  absence  of  other  causative  lesion,  is 
suggestive  of  tuberculosis.  As  the  affection  progresses  perinephric 
abscess  is  a  common  complication. 

The  determination  as  to  whether  one  or  both  kidneys  is  affected 
usually  depends  upon  ureteral  catheterization  and  the  injection  of  the 
urine  drawn  from  each  kidney  into  susceptible  animals. 


THE  KIDNEYS  691 

Syphilis  of  the  Kidney. — Syphilis  of  the  kidney  may  manifest  itself 
in  the  form  of  a  congestion,  shortly  (weeks)  following  the  chancre, 
characterized  by  a  slight,  transitory,  intermittent  albuminuria,  with 
possibly  hyaline  casts. 

In  the  secondary  period  (the  first  two  years  of  the  disease)  acute 
parenchymatous  nephritis  may  develop,  dependent  upon  the  syphilitic 
virus  or  its  toxins,  exhibiting  the  symptoms  of  this  condition  when  it  is 
due  to  other  causes  and  cured  by  specific  treatment. 

In  the  later  stages  of  the  disease  (after  two  years)  interstitial  nephritis 
may  develop. 

Aneurysm  of  the  Renal  Arteries. — Aneurysm  of  the  renal  arteries  is 
characterized  by  the  formation  of  a  postperitoneal  tumor,  following 
traumatism;  either  exhibiting  no  symptoms  or  characterized  by  profuse 
bleeding  into  the  pelvis  of  the  kidney  or  into  the  peritoneal  cavity. 

The  diagnosis  is  made  by  surgical  operation  or  autopsy,  since  the 
tumor  is  so  deeply  placed  that  neither  thrill,  bruit,  nor  pulsation  can 
be  detected.  The  possibility  that  a  renal  tumor  which  shortly  follows 
traumatism  and  is  accompanied  by  profuse  hematuria  may  be  an 
aneurysm  should  be  considered. 

Tumors  of  the  Kidney. — ^Tumors  of  the  kidney  are  commonest  in 
children  under  five  years  of  age,  usually  sarcomatous,  are  characterized 
by  profuse,  intermittent,  and  apparently  causeless  hematuria  (at  times 
associated  with  transitory  colic  from  ureteral  blocking  by  clots),  a  sense 
of  weight  or  pain  in  the  lumbar  region,  and  the  formation  of  a  rapidly 
growing  postperitoneal  tumor,  always  prominent  in  the  loin,  though  its 
direction  of  growth  may  be  either  upward,  forward,  or  both. 

The  tumor  is  usually  fixed,  hard,  bossed,  and,  if  small,  lies  behind  the 
colon.  If  it  attains  large  size,  this  viscus  may  be  pushed  completely  to 
one  side. 

Hypernephroma,  constituting  the  large  majority  of  renal  tumors 
observed  in  the  adult,  exhibits  the  clinical  features  of  sarcoma;  recurring, 
apparently  causeless,  often  profuse  bleeding,  and  the  development  of 
tumor.  The  favorite  seats  of  metastasis  are  the  long  bones,  the  liver, 
and  the  lungs. 

In  the  late  stages  of  malignant  disease  of  the  kidney  the  huge  size 
of  the  growth,  its  rapid  progression,  dilated  veins  of  the  abdomen,  and 
profound  cachexia  make  the  nature  of  the  affection  unmistakable.  Diag- 
nosis should  be  based  upon  the  results  of  operation  performed  when  free 
bleeding  without  obvious  cause  first  suggests  the  probability  of  neoplasm. 

The  lateral  position  of  the  tumor  and  the  lumbar  bulge  usually  enable 
a  distinction  to  be  made  from  retroperitoneal  sarcoma.  The  diagnosis 
from  renal  calculus  and  from  renal  tuberculosis  will  be  suggested  by 
the  slight  bleeding  characteristic  of  the  latter  conditions. 

Papilloma. — Papilloma  of  the  renal  pelvis  (rare)  is  characterized  by 
hematuria  or,  if  it  becomes  obstructive,  pain.  It  is  diagnosticated  only 
by  surgical  operation. 

Cystic  disease  of  the  kidneys  (congenital)  is  characterized  by  bilateral 
enlargement  of  slow  growth  (years)  unattended  with  hematuria.     There 


692  THE  GENITO-URINARY  ORGANS 

is  usually  associated  moderate  hydronephrosis.  Such  kidneys  are  sub- 
ject to  nephrolithiasis  and  pyelitis. 

The  diagnosis  is  based  upon  the  slow  enlargement,  this  distinguishing 
it  from  sarcoma.  The  bosselated  surface  of  the  tumor,  its  failure  to 
be  distinctly  outlined  by  the  a^-rays,  and  the  symptoms  of  a  progressive 
renal  incompetency  are  characteristic  features.  The  diagnosis  is  usually 
made  post  mortem. 

Hydatid  cyst  may  be  distinguished  from  hydronephrosis  only  by 
direct  examination,  excepting  in  the  case  of  rupture  into  the  pelvis  or 
ureter,  when  the  examination  of  the  urine  should  be  diagnostic. 

The  Adrenal  Glands. — The  adrenal  glands,  if  diseased  bilaterally 
and  extensively  (tuberculosis),  are  attended  with  emaciation,  anemia, 
adynamia,  vomiting  of  blood,  melena,  and  often  bronzing  of  the  skin 
(Addison's  disease). 

Tumor  of  the  suprarenal  capsule  usually  cannot  be  diagnosticated 
from  similar  conditions  involving  the  kidney  excepting  by  the  absence  of 
blood  from  the  urine.  Even  this  may  be  present  incident  to  pressure, 
congestion,  or  direct  renal  involvement.  The  adrenal  tumor  in  its  growth 
displaces  the  kidney  downward,  and  may  be  first  felt  in  the  epigastric 
region  to  the  right  or  the  left  of  the  middle  line.  General  and  pro- 
nounced outgrowth  of  hair  and  hypertrophy  of  the  genitalia  have  been 
noted.  Metastasis  to  the  orbital  region  is  characteristic  of  one  form 
of  sarcoma. 

Cysts  of  the  suprarenal  gland  (rare),  of  slow  growth  (years),  and 
probably  secondary  to  embolus  or  hemorrhage,  form  thoraco-abdominal 
tumors,  the  origin  of  which  even  operation  has  at  times  failed  to  demon- 
strate. 


CHAPTEE    XIX. 

GYNECOLOGICAL  DLIGNOSIS. 
By  BROOKE  M.  ANSPACH,  M.D. 

Gynecological  diagnosis  depends  upon  the  histon^,  the  symptoms, 
and  the  physical  examination.  To  correctly  determine  each  of  them, 
one  must  be  familiar  with  the  normal  anatomy  of  the  reproductiye 
organs,  with  the  yarious  gynecological  diseases,  and  with  both  the  sub- 
jectiye  and  the  objectiye  manifestations  of  pelvic  disorders. 

The  Anatomy  of  the  Reproductive  Organs. — The  genital  organs 
may  be  divided  for  the  purpose  of  description  into  the  external,  the 
intermediate,  and  the  internal  genitalia.  The  external  genital  organs, 
collectively  known  as  the  vulva,  are  boimded  bv  the  labia  majora,  the 
pubes,  and  the  perineal  body.  The  vulva  comprises  the  labia  majora, 
the  labia  minora,  the  clitoris,  the  external  urinary  meatus,  the  vestibule, 
the  hymen,  the  ostium  vaginae,  and  the  fourchette.  It  is  covered  with  a 
modified  skin  which  is  thinner  than  the  general  cutaneous  covering,  and 
contains  sebaceous  and  sudoriferous  glands. 

The  vulvovaginal  glands  are  two  distinct  bodies,  each  about  the  size 
of  a  bean,  embedded  in  the  lower  part  of  the  labia  majora,  on  either 
side  of  the  introitus  vaginae.  The  ducts  open  upon  the  ■vT.dvar  surface 
about  the  middle  of  the  vaginal  orifice  and  just  in  front  of  the  hymen. 
The  secretion  is  mucous.  The  perineal  body  lies  between  the  vaginal 
introitus  and  the  anus.  It  is  the  musculofibrous  intersection  of  the 
transversus  perinei,  the  bulbus  cavernosum,  the  levator  ani,  and  the 
sphincter  ani  muscles.  At  the  external  urinary  meatus  are  t^'o  invagi- 
nations of  the  urethral  mucosa  known  as  Skene's  tubules.  They  are 
each  about  |  of  an  inch  in  length  and  open  on  the  urethral  surface  just 
within  the  meatus.  In  the  multiparous  women  the  orifices  are  visible 
as  small  openings  of  sufficient  size  to  admit  a  bristle. 

The  vagina  extends  from  the  vulva  to  the  cervix,  which  it  surrounds 
and  to  which  it  is  attached.  The  ballooned-out  upper  part  of  the  vagina 
into  which  the  cervix  projects  is  known  as  the  vaginal  fornix.  The 
vaginal  walls  in  the  normal  nulliparous  woman  are  in  contact,  except 
at  the  introitus  and  at  the  vaginal  fornix.  The  posterior  wall  is  held 
against  the  anterior  wall  by  the  support  it  receives  from  the  levator  ani 
and  the  other  muscles  and  fasciae  of  the  pelvic  floor.  The  anterior 
border  of  the  levator  ani  muscle  can  be  felt  in  the  normal  woman  just 
within  the  vaginal  orifice,  on  either  side,  its  fibers  forming  a  band 
about  one-half  inch  in  thickness.  The  vagina  is  lined  by  a  modified 
skin  very  much  like  that  of  the  vulva  and  containing  no  glands.  It 
is  moistened  bv  the  so-called  vao;inal  secretion  which  consists  of  the 


694  GYNECOLOGICAL  DIAGNOSIS 

discharge  from  the  cervix  and  the  uterus,  desquamated  epithehum, 
and  transuded  blood  serum. 

The  cervix  projects  into  the  vaginal  fornix.  It  is  covered  by  a 
reflection  of  the  vaginal  mucosa  as  far  as  the  external  os,  where  the 
mucosa  of  the  cervical  canal  begins.  It  has  a  smooth,  grayish  red 
appearance.  The  external  os  is  usually  plugged  with  clear,  thick  mucus. 
The  cervix  points  toward  the  coccyx  and  its  axis  is  nearly  at  right 
angles  to  that  of  the  vagina. 

The  body  of  the  uterus  is  flexed  gently  forward  upon  the  cervix 
and  lies  within  the  cavity  of  the  true  pelvis.  Its  anterior  surface  is  in 
relation  with  the  superior  surface  of  the  bladder.  As  the  bladder  fills 
with  urine,  the  fundus  of  the  uterus  is  pushed  upward  and  backward. 

The  pelvic  peritoneum  covers  the  anterior  and  the  posterior  surface 
of  the  uterus,  dipping  down  between  the  body  of  the  uterus  in  front  to 
about  the  level  of  the  internal  os,  and  then  being  reflected  forward  upon 
the  bladder.  Posteriorly  the  peritoneum  covers  the  entire  surface  of  the 
uterus  and  thence  is  reflected  to  the  pelvic  wall,  partially  surrounding 
the  rectum.  The  peritoneal  space  thus  formed  between  the  uterus  and 
the  rectum  is  known  as  Douglas'  pouch. 

The  tubes  and  ovaries  lie  at  the  side  of  and  posterior  to  the  uterus. 
They  are  held  in  position  by  the  broad  ligaments  which  run  from  the 
lateral  borders  of  the  uterus  to  the  pelvic  wall,  and  by  the  uteroovarian 
and  the  infundibulopelvic  ligaments.  The  outer  extremities  of  the  tubes 
are  open  and  communicate  with  the  peritoneal  surface  of  the  pelvis. 
The  ovary  is  not  covered  by  the  peritoneum,  but  projects  from  the 
posterior  peritoneal  surface  of  the  broad  ligament. 

The  uterine  ligaments  consist  of  the  broad,  the  uterosacral,  the  utero- 
vesical,  and  the  round  ligaments.  All  of  these  but  the  last  mentioned 
are  formed  by  foldings  of  the  pelvic  peritoneum,  enclosing  between  them 
fatty  connective  tissue,  a  few  muscle  fibers,  bloodvessels,  and  nerves.  The 
round  ligaments  are  distinct  fibromuscular  structures  which  pass  from 
the  cornua  of  the  uterus  through  the  inguinal  canals  to  the  pubes. 

The  body  of  the  uterus  is  lined  by  a  mucous  membrane  known  as  the 
endometrium.  It  is  continuous  with  the  mucosa  of  the  cervical  canal 
at  the  internal  os  and  with  that  of  the  tubes  at  the  uterine  cornua. 
Within  the  tube  the  mucosa  is  thrown  into  folds  and  at  the  outer 
extremity  projects  into  the  peritoneal  cavity  as  a  fringe-like  formation, 
spoken  of  as  the  fimbria. 

GENERAL  CONSIDERATION  OP  THE  HISTORY  AND  OF  THE 

SYMPTOMS. 

The  age  and  the  social  position  of  the  patient  may  direct  the  physician 
to  a  certain  extent  in  collecting  the  data  for  a  diagnosis. 

Diseases  Occurring  before  the  Age  of  Puberty. — Only  a  few  gynecologi- 
cal diseases  are  found  before  the  age  of  puberty.  Gonorrheal  vulvo- 
vaginitis, malignant  tumor  (cystic  or  solid)  of  the  ovary,  grape-like 
sarcoma  of  the  cervix,  and  tuberculous  salpingitis  and  peritonitis  are 


CONSIDERATION  OF  THE  HISTORY  AND  SYMPTOMS         695 

those  most  often  encountered.  Sometimes  a  catarrhal  inflammation 
of  the  tube  occurs  during  the  course  of  one  of  the  acute  exanthematous 
diseases;  ovaritis  may  compHcate  mumps,  scarlet  fever,  or  smallpox. 
These  complications  produce  abdominal  pain  which  is  usually  mis- 
interpreted and  the  disease  escapes  "attention.  At  some  time  subse- 
quently, however,  the  result  of  the  pelvic  inflammation  may  become 
manifest  in  hydrosalpinx,  adherent  adnexa,  or  adherent  retroposition 
of  the  uterus;  sterility  may  be  caused  by  light  velamentous  adhesions 
covering  the  tubal  ostia.  Congenital  malformations,  except  gross 
deformities  of  the  external  genitalia,  do  not  become  noticeable,  as  a 
rule,  until  puberty. 

Diseases  Occurring  after  Puberty  and  during  Adolescence. — ^Affections 
which  manifest  themselves  at  puberty  are  either  the  result  of  a  mal- 
formation of  some  part  of  the  genital  apparatus  or  an  evidence  of  general 
ill-health.  Thus,  a  tumor  arising  from  any  of  the  forms  of  gynatresia 
(hematocolpos,  hematometra,  hematosalpinx),  or  subjective  evidence 
of  functional  or  anatomical  insufficiency  of  the  genitalia  (amenorrhea, 
dysmenorrhea)  may  appear.  Malignant  tumor  (cystic  and  solid)  of 
the  ovary,  grape-like  sarcoma  of  the  cervix,  and  tuberculosis  of  the  tubes 
and  of  the  pelvic  peritoneum  are  more  frequent  than  before  puberty. 

As  adult  life  is  approached,  gonorrhea  and  pregnancy  are  encountered 
in  the  married  and  in  the  non-virginal. 

Diseases  Occurring  between  the  Ages  of  Twenty-one  and  Forty  in  the 
Unmarried  and  Virginal. — The  various  lesions  due  to  gonorrheal  infection 
and  to  pregnancy  and  childbirth  may  be  excluded.  Dysmenorrhea  of 
the  neuralgic  type,  the  result  of  a  lowered  general  body  tone,  may  develop 
in  those  who  lead  an  unhygienic  life. 

Neurasthenia  and  the  various  neuroses  will  be  met,  the  subjects  fre- 
quently having  a  fixed  and  erroneous  idea  concerning  their  pelvic  organs. 
A  congenital  or  a  traumatic  displacement  of  the  uterus  may  become 
manifest.  Endometritis  or  some  general  affection  may  be  indicated  by 
leucorrhea  or  menorrhagia.  Fibroid  tumor  and  endometrial  polyp  are 
not  uncommon. 

Diseases  Occurring  between  the  Ages  of  Twenty-one  and  Forty  in  the 
Married  and  in  the  Non-virginal. — ^The  whole  gamut  of  disorders  caused 
by  the  gonococcus  is  found  in  this  class.  Pregnancy,  normal  and  path- 
ological, and  its  results  are  encountered.  Pelvic  inflammatory  disease, 
displacements  of  the  uterus,  lacerations  of  the  cervix  and  of  the  pelvic 
floor  are  common.  Fibroid  tumors  occur,  especially  in  those  who  have 
been  sterile  or  who  give  the  history  of  repeated  miscarriages. 

Diseases  Occurring  between  the  Ages  of  Forty  and  Sixty. — ^The  diseases 
associated  with  the  menopause  and  with  old  age  include  ovarian  cysts, 
carcinoma  of  the  cervix,  carcinoma  of  the  fundus,  extreme  degrees  of 
displacement  of  the  uterus,  laceration  and  hypertrophy  of  the  cervix, 
cystocele,  and  rectocele.  Carcinoma  of  the  cervix  almost  never  occurs 
in  those  who  have  borne  no  children.  Carcinoma  of  the  body  of  the 
uterus  frequently  occurs  in  sterile  women  and  in  combination  with 
fibroid  tumors  of  the  uterus. 


696  GYNECOLOGICAL  DIAGNOSIS 

The  Time  of  Onset  of  the  Symptoms. — The  time  of  the  onset  of  the 
symptoms  may  furnish  a  clue  to  the  diagnosis.  Thus,  developmental 
anomalies  are  first  detected  at  the  time  of  puberty  or  after  marriage. 
Gonorrheal  infection  and  all  of  its  sequelae  date  from  suspicious  inter- 
course or  from  marriage.  Gonorrheal  endometritis  or  peritonitis  in  a 
woman  already  infected  frequently  begins  at  or  about  the  time  of  the 
menstrual  period.  The  onset  of  the  symptoms  of  displacement  of  the 
uterus,  laceration  of  the  cervix,  and  relaxation  of  the  pelvic  floor  will 
customarily  be  referred  to  childbirth. 


GYNECOLOGICAL  SYMPTOMS  IN  DETAIL. 

Pain. — Pain  varies  in  character,  location,  and  time  of  occurrence. 

Character. — Pain  may  be  dull,  sharp,  neuralgic,  or  cramp-like.  Dull 
pain  is  most  common  in  displacements  of  the  uterus  and  in  relaxations 
of  the  pelvic  floor.  It  may  arise  also  as  a  result  of  pressure  from  a 
pelvic  tumor.  Dull  pain  is  sometimes  associated  with  a  dragging  sensa- 
tion in  cases  of  relaxation  of  the  pelvic  floor  and  in  displacements  of  the 
uterus. 

Sharp,  lancinating  pain  is  usually  found  in  inflammatory  affections 
of  the  pelvic  peritoneum  and  the  adnexa.  The  pain  at  the  time  of 
rupture  of  a  tubal  pregnancy  is  often  spoken  of  as  lancinating. 

Neuralgic  pain  is  found  in  diseases  which  produce  compression  or 
infiltration  of  nerve  sheaths.  The  most  familiar  examples  of  neuralgic 
pains  are  found  in  carcinoma  of  the  cervix  (infiltration  and  compression), 
tumors  which  block  the  pelvis  (compression),  and  dense  inflammatory 
masses  (compression  and  infiltration). 

Cramp-like  pain,  or  the  pain  associated  with  muscular  contractions, 
occurs  from  the  efforts  of  the  uterus  to  expel  a  foreign  body,  as,  for 
example,  a  piece  of  placenta,  a  pedunculated  submucous  fibroid  tumor, 
or  an  endometrial  polyp.  Cramp-like  pains  also  occur  from  tubal  con- 
tractions in  tubal  pregnancy  preceding  tubal  abortion  or  rupture. 

Burning  pain  accompanies  acute  inflammation  of  the  vulva,  vagina, 
and  bladder.     It  is  also  found  in  urethral  caruncle. 

A  sensation  of  loss  of  support  is  complained  of  in  relaxation  of  the 
pelvic  floor. 

Location. — External  Genitalia. — Pain  from  inflammatory  and  other 
affections  of  the  vulva  or  the  vagina  is  usually  felt  in  the  external 
genitalia,  perineum,   and  groin. 

Bladder. — ^A  burning  pain  with  frequency  of  urination  may  be  found 
in  inflammatory  affections  of  the  urethra  and  the  bladder,  in  relaxation 
of  the  pelvic  floor,  in  prolapsus  of  the  uterus  with  cystocele,  in  retro- 
position  of  the  uterus,  in  fibroid  tumor  (pressure  on  the  bladder),  and 
in  pelvic  inflammatory  diseases  of  all  types  when  the  bladder  is  involved. 
Frequent  and  painful  urination  which  is  due  to  displacement  of  the 
uterus  or  relaxation  of  the  pelvic  floor  disappears  when  the  organs  are 
replaced  and  maintained  in  good  position. 


GYNECOLOGICAL  SYMPTOMS  IN  DETAIL  697 

Pain  in  the  Rectum. — A  feeling  of  pressure  and  pain  in  the  rectum 
is  found  in  cases  of  rectocele,  especially  during  attempts  at  defecation. 
In  extreme  degrees  of  retroposition,  when  the  body  of  the  uterus  presses 
against  the  bowel,  the  patient  may  complain  of  a  sensation  as  if  a  foreign 
body  were  in  the  rectum.  An  intense  desire  to  defecate  is  often  associated 
with  pelvic  hematocele.  Pain  during  defecation  is  sometimes  observed 
in  prolapsus  of  the  ovary. 

Pain  in  the  lower  abdomen  in  the  median  line  is  found  in  relaxation  of 
the  pelvic  floor,  in  pathological  anteflexion,  retroposition,  and  prolapse 
of  the  uterus,  and  in  uterine  fibroids,  especially  of  the  intramural  or  the 
submucous  type. 

Pain  in  the  lower  abdomen  at  the  sides  is  found  in  pelvic  inflammatory 
disease  and  in  tubal  and  ovarian  affections  such  as  extra-uterine  preg- 
nancy, cystic  ovary,  prolapsed  ovary,  and  ovarian  cyst. 

Backache  in  the  sacral  region,  vertical  headache,  and  pain  along  the 
front  or  the  back  of  the  thighs  are  referred  sensations,  and  may  be 
present  in  a  variety  of  gynecological  diseases.  Backache  is  especially 
prone  to  be  associated  with  relaxation  of  the  pelvic  floor  and  displace- 
ment of  the  uterus.  The  same  may  be  said  of  vertical  headache.  Pains 
which  are  referred  to  the  thighs  are  the  result  of  pressure  on  the  sciatic, 
the  obturator,  or  the  crural  nerves,  and  may  be  produced  by  any  tumor 
or  inflammatory  affection. 

The  Time  of  the  Occurrence  of  Pain. — Pain  due  to  a  relaxation  of  the 
pelvic  floor  and  to  a  displacement  of  the  pelvic  organs  is  less  when  the 
patient  is  in  bed;  it  gradually  increases  when  the  patient  gets  up  and 
goes  about  or  works.  The  pain  is  always  relieved  by  assuming  a  recum- 
bent position. 

Rheumatic  pain  in  the  back  and  limbs  is  worse  on  arising  from  bed, 
and  becomes  less  as  the  muscles  of  the  back  and  thighs  are  called  into 
use. 

Inflammatory  pain  is  but  little  influenced  by  rest,  unless  it  keeps 
inflamed  surfaces  apart  or  reduces  muscular  tension  over  inflamed 
areas. 

Menstrual  Symptoms. — The  menstrual  symptoms  which  are  met  in 
gynecological  diseases  are  amenorrhea,  scanty  menstruation,  acute 
suppression  of  the  menstrual  flow,  menorrhagia,  metrorrhagia,  and 
dysmenorrhea. 

Amenorrhea  is  an  absence  of  menstruation.  This  term  does  not 
apply  to  the  absence  of  menstruation  during  pregnancy.  Nor  can  it 
be  truly  used  in  cases  of  retention  of  the  menstrual  flow  because  of  an 
imperforate  hymen  or  in  any  form  of  gynatresia  (hematocolpos,  hemato- 
metra,  hematosalpinx).  In  such  instances  the  flow  occurs,  but  is  not 
visible  for  obvious  reasons. 

Amenorrhea  may  depend  upon  an  anatomical  lesion  of  the  uterus 
or  of  the  ovaries  which  renders  menstruation  impossible,  e.  g.,  hyper- 
involution  of  the  uterus;  ovaritis  complicating  parotitis,  scarlet  fever, 
or  smallpox;  bilateral  sarcoma  or  carcinoma  or  atrophy  of  the  ovary 
or  fatty  degeneration  of  the  ovary  associated  with  general  obesity. 


698  GYNECOLOGICAL  DIAGNOSIS 

Amenorrhea  may  be  the  result  of  diseases  which  affect  the  general 
health,  such  as  chlorosis,  typhoid  fever,  tuberculosis,  myxedema,  Base- 
dow's disease,  diabetes,  carcinoma  outside  of  the  genital  tract,  gastric 
catarrh,  leukemia,  acromegaly,  or  Addison's  disease. 

Amenorrhea  may  have  a  psychical  cause,  such  as  the  fear  of  impreg- 
nation, the  desire  for  impregnation,  terrible  fright,  altered  social  rela- 
tions, or  a  change  of  climate. 

Scanty  menstruation  is  etiologically  similar  to  amenorrhea.  The 
cause  is  less  active  in  the  case  of  scanty  menstruation. 

Suppression  of  the  Menstrual  Flow. — ^A  sudden  cessation  of  the  men- 
trual  flow  occurs  as  the  result  of  wet  feet  or  of  insufficient  clothing  for 
the  lower  extremities.  Sea-bathing,  the  use  of  a  cold  douche,  and  psychic 
influences  will  also  produce  it.  The  menstrual  flow  sometimes  ceases 
abruptly  during  an  attack  of  gonorrheal  endometritis  or  peritonitis. 

Menorrhagia  is  an  increase  in  the  amount  or  the  duration  of  the 
menstrual  flow. 

Metrorrhagia  is  a  uterine  hemorrhage  which  occurs  between  the  men- 
strual periods.  It  is  to  a  large  extent  dependent  upon  the  same  causes 
as  menorrhagia.  Metrorrhagia  represents  the  extreme  effect  of  a  cause 
which  may  have  first  produced  menorrhagia.  The  causes  of  menor- 
rhagia and  metrorrhagia  are  general  and  local. 

The  general  causes  are:  Cardiac  incompetency,  cirrhosis  of  the 
liver,  interstitial  nephritis,  the  hemorrhagic  diathesis,  scurvy,  typhoid 
fever,  cholera,  variola,  scarlatina,  influenza,  acute  articular  rheumatism, 
and  syphilis,  secondary  or  tertiary. 

The  local  causes  are:  Endometritis,  endometrial  polyp,  subinvolution 
of  the  uterus,  relaxation  of  the  uterine  muscle,  retrodisplacement  of  the 
uterus,  fibroid  tumor,  carcinoma  or  sarcoma  of  the  uterus,  tubal  pregnancy, 
cystic  degeneration  of  the  ovary,  and  carcinomatous  ovarian  tumors. 

The  source  and  the  cause  of  menorrhagia  and  metrorrhagia  should 
be  investigated  in  every  instance.  It  should  be  remembered  that 
metrorrhagia  is  usually  the  first  symptom  of  cancer.  This  symptom  in 
a  woman  past  forty  years  of  age  should  always  arouse  the  greatest 
anxiety  until  malignant  disorders  are  excluded. 

Dysmenorrhea  is  a  word  used  to  designate  pain  of  varying  type  and 
location  which  is  definitely  associated  with  the  menstrual  flow.  Dys- 
menorrhea usually  signifies  sharp,  cramp-like  pain  in  the  lower  abdomen. 
But  severe  headache  and  backache  and  dull  pain  in  the  hips  and  ovarian 
regions  also  constitute  a  form  of  dysmenorrhea. 

Dysmenorrhea  may  be  due  to  congenital  defects  such  as  infantile  type 
of  uterus,  ill-developed  fundus,  long,  conical  or  short,  knob-like  cervix, 
or  sharp  anteflexion  or  stenosis  of  the  cervix.  Congenital  defects  of  the 
nervous  mechanism  may  also  be  responsible  for  the  neuralgic  type  of 
dysmenorrhea. 

Dysmenorrhea  may  be  symptomatic  of  almost  any  of  the  acquired 
pelvic  lesions,  e.  g.,  endometritis,  retroposition  of  the  uterus,  fibroid 
tumor  of  the  uterus,  uterine  polyp,  inflammatory  diseases  of  the  adnexa, 
ovarian  tumors,  etc. 


GYNECOLOGICAL  SYMPTOMS  IN  DETAIL  699 

Dysmenorrhea,  the  result  of  obstruction  to  the  cervical  canal,  ante- 
flexion, stenosis,  etc.,  commonly  consists  of  cramp-like  pain  in  the  lower 
abdomen  which  precedes  the  menstrual  discharge  from  twenty-four  to 
thirty-six  hours  and  is  relieved  as  soon  as  the  flow  is  well  estabhshed. 
In  dysmenorrhea  associated  with  fibroid  tumor,  endometrial  polyp, 
endometritis,  or  retroposition  of  the  uterus,  the  pain  starts  with  the 
flow  and  continues  throughout  the  period. 

Dysmenorrhea  from  chronic  pelvic  inflammatory  disease  or  cystic 
degeneration  of  the  ovaries  takes  the  form  of  a  dull,  heavy  ache  in  the 
lower  abdomen  and  hips  which  precedes  the  appearance  of  the  menstrual 
flow  and  then  gradually  subsides.  The  neuralgic  form  of  dysmenor- 
rhea may  simulate  any  of  these.  Usually  it  partly  simulates  that  due 
to  obstruction,  viz.,  the  cramp-like  pains  begin  prior  to  the  establish- 
ment of  the  menstrual  flow,  but,  unlike  the  obstructive  type,  they  con- 
tinue throughout  the  period,  not  being  relieved  by  the  escape  of  the 
menstrual  blood.  The  neuralgic  form  sometimes  consists  of  a  dull, 
heavy  sensation  in  the  lower  abdomen,  the  ovarian  regions,  and  the 
thighs,  preceding  the  period,  and  frightful  headache  and  backache  during 
the  flow. 

Leucorrhea. — Leucorrhea  is  a  symptom  of  numerous  gynecological 
disorders.     It  may  be  mucous,  mucopurulent,  purulent,  or  putrid  in  type. 

Mucous  leucorrhea  results  from  catarrh  of  the  vulvovaginal  glands 
and  the  cervix.     Cervical  mucus  is  extremely  thick  and  tenacious. 

Mucopurulent  leucorrhea  results  from  an  infection  of  the  vulvovaginal 
and  the  cervical  glands.  As  the  disease  progresses  the  discharge  may 
become  purulent. 

Purulent  leucorrhea  originates  from  vulvitis,  urethritis,  vaginitis,  ulcer- 
ative diseases  of  the  vulva  and  the  vagina,  and  acute  endometritis. 

Serous  leucorrhea,  a  thin  watery  leucorrhea,  is  noted  in  chronic  endome- 
tritis, in  the  early  stage  of  some  cases  of  carcinoma  of  the  corpus  uteri, 
in  fibroid  tumor,  in  early  sarcoma  of  the  uterus,  in  chronic  pelvic  con- 
gestion, and  in  constitutional  debility. 

Putrid  leucorrhea  is  noted  in  carcinoma  and  sarcoma  of  any  part  of 
the  genital  tract,  the  peculiar  odor  occurring  as  soon  as  infection  and 
necrosis  of  the  newgrowth  takes  place.  A  sloughing,  or  necrotic, 
fibroid  tumor  or  endometrial  polyp,  retained  and  putrefying  secundines, 
or  decidual  tissue  produces  the  same  result. 

Constipation. — Chronic  constipation  is  noted  in  retrodisplacements 
of  the  uterus,  in  fibroid  tumors  of  the  uterus,  or  in  other  pelvic  tumors 
which  encroach  upon  the  rectum.  Constipation  is  also  noted  in  pelvic 
inflammatory  diseases,  both  in  the  acute  and  in  the  chronic  stage. 

Pruritus  Vulvse. — Pruritus  vulvae  is  often  indicative  of  an  irritating 
discharge,  but  it  may  be  a  symptom  of  many  disorders.  In  the  severest 
form  it  is  accompanied  by  local  lesions.  It  is  discussed  under  diseases 
of  the  vulva  on  page  708. 

Fever. — Most  of  the  inflammatory  diseases  are  accompanied  by  fever. 
In  acute  gonorrhea  of  the  urethra,  vulvovaginal  glands,  and  the  cervix 
it  is  usually  slight.     Abscess  of  the  vulvovaginal  glands,  acute  endome- 


700  GYNECOLOGICAL  DIAGNOSIS 

tritis,  acute  pelvic  peritonitis,  and  acute  salpingitis  and  ovaritis  are 
accompanied  by  a  considerable  degree  of  pyrexia.  In  tubal  pregnancy 
(before  rupture)  there  is  often  some  rise  of  temperature. 

Sterility. — A  w^oman  is  said  to  be  sterile  when  conception  does  not 
occur  within  three  years  after  marriage.  This  is  an  arbitrary  statement, 
and  is,  of  course,  modified  by  the  condition  of  the  husband  and  by  any 
means  which  have  been  used  to  prevent  conception.  Relative  sterility 
— "one  child  sterility" — is  the  common  result  of  an  ascending  gonorrheal 
infection  occurring  in  the  first  and  only  puerperium.  Sterility  on  the 
part  of  the  woman  may  be  due  to  imperfect  development,  inflammatory 
disease  and  its  result,  or  to  some  functional  or  mechanical  difficulty 
which  renders  the  sexual  act  faulty  or  keeps  the  spermatic  particles 
from  meeting  the  ovum. 

Developmental  Sterility. — The  following  defects  may  prevent  impreg- 
nation: Hyperplasia  of  the  ovaries  (few  and  imperfectly  formed  ova), 
fetal  type  of  Fallopian  tube  (the  tube  is  long  and  very  much  twisted), 
diverticula  of  the  tubal  canal  (ovum  is  caught  in  a  blind  passage  and 
arrested  in  its  progress  toward  the  uterus),  infantile  or  fetal  type  of 
uterus  (the  fertilized  ovum  is  badly  embedded  and  perishes),  stenosis 
of  the  cervix  (spermatic  particles  cannot  enter  the  uterus),  elongation 
of  the  cervix  and  flattening  of  the  vaginal  fornices  (the  semen  is  expelled 
from  or  runs  out  of  the  vaginal  vault  almost  directly  after  it  is  deposited 
there),  malformation  of  the  vagina  or  the  external  genitalia  (normal 
intercourse  or  the  entrance  of  the  spermatic  particle  is  difficult  or 
impossible). 

Sterility  Depending  on  Pelvic  Inflammatory  Diseases. — Any  inflam- 
matory disease  which  closes  the  abdominal  ostia  of  the  tubes  or  produces 
kinking  and  contraction  of  the  lumen  of  the  tube  may  lead  to  sterility. 
Dense  adhesions  of  the  ovary  prevent  rupture  of  the  Graafian  follicles, 
cervical  gonorrhea  destroys  the  spermatozoon  or  prevents  its  ingress; 
endometritis  renders  difficult  the  embedment  of  the  ovum  after  it  has 
been  fertilized. 

Salpingitis  and  ovaritis  complicating  the  exanthemata  in  early  life 
may  result  in  thin  velamentous  adhesions  about  the  tubal  ostia. 

Mechanical  impediments  to  the  ingress  of  the  spermatic  particles,  such 
as  acute  anteflexion  or  retroflexion,  fibroid  tumor,  or  adenomatous  polyp, 
may  account  for  sterility;  a  lacerated  or  an  everted  cervix  may  prevent 
conception  because  of  the  displacement  of  the  external  os. 

Functional  sterility  may  be  due  to  vaginismus  or  to  incompatibility 
between  the  male  and  the  female. 


METHODS  OF  EXAMINATION. 

The  same  methods  of  examination  which  are  employed  for  physical 
diagnosis  in  general  are  used  in  gynecology.  On  account  of  the 
anatomy  of  the  parts,  certain  positions  are  required  in  order  to  satisfac-^ 
torily  conduct  the  examination,  and  certain  instruments  or  devices  are 


METHODS  OF  EXAMINATION 


701 


of  service.  While  the  physical  examination  includes  inspection,  pal- 
pation, percussion,  and  auscultation,  the  most  valuable  are  inspection 
and  palpation.  Percussion  is  useful  in  the  diagnosis  of  pelvic  tumors 
which  encroach  upon  the  abdominal  cavity.  Auscultation  is  scarcely 
ever  used  except  in  the  diagnosis  of  pregnancy.  Palpation  is  the  sine 
qua  non  of  gynecological  examinations.  Inspection  is  a  valuable  aid 
and  should  precede  the  others. 

Position  of  the  Patient. — For  a  routine  examination  the  dorsal  position 
is  the  best.  The  patient  lies  upon  her  back  with  the  thighs  well  flexed 
upon  the  abdomen  and  the  knees  widely  separated.     The  legs  are  flexed 

Fig.  435 


Dorsal  position.      Bimanual  or  abdominovaginal  examination. 


on  the  thighs  and  the  feet  are  held  either  by  stirrups  suspended  from 
upright  rods,  or  by  foot-rests  at  the  end  of  the  examining  table.  The 
buttocks  should  project  slightly  over  the  edge  of  the  table.  If  necessary, 
the  patient  can  be  examined  in  bed.  She  should  lie  across  it  with  her 
buttocks  resting  on  the  edge,  the  shoulders  and  head  elevated  by  a 
pillow,  the  knees  widely  separated,  drawn  upv/ard,  and  supported  by 
assistants. 

Sims'  Position;  Knee-chest  Position — The  Sims  position  or  the  knee- 
chest  position  is  advisable  when  inspection  of  the  vaginal  vault  or  of 


702 


GYNECOLOGICAL  DIAGNOSIS 


the  anterior  vaginal  wall  is  desired.  These  positions  are  also  of  value 
in  cystoscopic  or  in  proctoscopic  examinations.  In  Sims'  position, 
the  patient  lies  on  the  left  side  with  the  left  arm  behind  her;  the  trunk 
is  rotated  so  that  the  front  of  the  chest  lies  in  contact  with  the  table; 
the  thighs  are  flexed  at  right  angles  to  the  abdomen  and  the  legs  at 
right  angles  to  the  thighs;  the  right  thigh  is  flexed  more  than  the  left, 
so  that  the  right  knee  lies  above  the  left.  A  small,  firm  pillow  placed 
beneath  the  hips  will  increase  the  efiiciency  of  this  position  by  securing 
greater  inclination  of  the  pelvis.     In  assuming  the  knee-chest  position. 

Fig.  436 


Knee-chest  position. 


the  patient  kneels  upon  the  edge  of  the  table,  sinking  the  chest  to  the 
surface  and  spreading  the  arms  to  either  side,  the  elbows  being  flexed; 
the  face  is  turned  to  one  side.  The  thighs  must  be  vertical,  the  chest 
must  rest  upon  the  table,  the  spinal  column  must  be  relaxed,  and  the 
lumbar  curve  exaggerated. 

Position  for  Abdominal  Examination. — When  pelvic  disease  causes 
distention  of  the  abdomen,  or  in  any  case  of  abdominal  enlargement 
when  pelvic  disease  is  suspected,  an  examination  of  the  abdomen 
should  follow  the  pelvic  examination.  For  this  purpose  the  patient 
should  lie  flat  on  her  back  with  the  knees  and  the  shoulders  slightly 
elevated  by  pillows. 

Preparation  of  the  Patient  for  an  Examination.^ — ^The  sigmoid  flexure 
and  the  rectum  should  be  thoroughly  evacuated.  The  bladder  should 
be  emptied  voluntarily  or  by  catheterization,  except  in  a  case  where 
it  is  especially  desirable  to  observe  the  presence,  the  nature,  and  the 
amount  of  a  leucorrheal  discharge.  Under  such  circumstances  a  pre- 
liminary inspection  should  be  made  several  hours  after  urination  or 
defecation.     A  douche  should  never  be  given  previous  to  the  first  gyne- 


METHODS  OF  EXAMINATION  703 

cological  examination.     The  clothing  about  the  waist  should  be  loosened. 
Constricting  bands  should  be  unfastened. 

Armamentarium. — Lubricant. — ^A  very  satisfactory  lubricant  for  the 
fingers  in  pelvic  examinations  is  composed  of 

Gum  tragacanth 3v  to  gr.  xlviij 

Carbolic  acid  TTL  xxxij 

Glycerin 3iij 

Water 5xxxij 

Petroleum  jelly  or  oil  may  be  used;  it  protects  the  fingers  more  than 
a  watery  paste,  but  is  harder  to  wash  off  and  is  more  objectionable  to 
the  patient.  Whatever  lubricant  is  chosen,  it  should  be  expressed 
from  a  collapsible  tube  or  poured  upon  the  fingers. 

Rubber  Gloves. — ^The  hand  should  be  protected  by  a  rubber  glove 
whenever  infection  of  any  sort  is  probable  in  a  vaginal  examination,  and 
always  in  digital  palpation  of  the  rectum.  The  transference  of  infec- 
tion from  the  vagina  to  the  rectum  or  vice  versa  should  be  carefully 
avoided. 

Specula. — ^Howard's  or  Graves'  bivalve,  or  Nott's  trivalve  speculum, 
is  used  in  the  dorsal  position.  In  the  Sims  or  in  the  knee-chest  position 
the  Sims  speculum  is  required.  Every  speculum  should  be  well  lubri- 
cated before  it  is  inserted.  It  should  be  introduced  with  its  greater 
diameter  in  the  oblique  axis  of  the  vagina  and  then  turned  to  the  desired 
position.  The  bivalve  and  the  tribladed  specula  hold  the  vaginal  walls 
apart,  exposing  the  cervix  and  that  part  of  the  vaginal  surface  which 
lies  between  the  blades.  The  Sims  speculum  retracts  the  posterior 
vaginal  wall  and  favors  atmospheric  distention  of  the  vagina,  the 
patient  being  in  the  knee-chest  or  the  Sims  position;  in  this  way  the 
entire  anterior  vaginal  wall,  the  cervix,  and  the  vaginal  vault  are  exposed. 

As  a  rule,  examination  of  virginal  women  should  be  made  under  the 
influence  of  an  anesthetic.  Palpation  should  be  made  per  rectum.  If 
inspection  of  the  cervix  is  necessary,  a  large-sized  Kelly  cystoscope  or 
the  smallest  trivalve  speculum  may  be  used. 

Pelvic  Examination.— Inspection  of  the  external  genitalia  should  be 
the  first  step  in  a  pelvic  examination.  The  existence  of  a  leucorrheal 
discharge  and  the  presence  of  venereal  sores  or  any  other  lesions  of  the 
vulva  may  be  detected  in  this  way.  Inspection  will  often  give  at  once 
certain  valuable  information.  For  example,  a  virginal  introitus  will 
exclude  the  diseases  due  to  pregnancy  and  childbirth;  a  reddening  of 
the  orifices  of  Skene's  tubules  and  of  the  ducts  of  the  vulvovaginal 
glands  will  suggest  gonorrheal  infection.  An  imperforate  hymen  will 
explain  an  absence  of  the  menstrual  flow.  Extensive  lacerations  of  the 
perineum,  cystocele,  rectocele,  etc.,  are  often  revealed  at  a  glance. 

The  cervix  and  the  vaginal  fornices  are  exposed  by  means  of  a%peculum. 
The  state  of  the  vaginal  mucosa,  whether  bathed  in  leucorrheal  discharge 
or  bereft  of  its  natural  moisture,  and  the  presence  of  erosions  or  inflam- 
mation can  be  observed  immediately.  The  contour  of  the  cervix 
the  amount  and  the  character  of  the  cervical  discharge,  and  any  gross 


704  GYNECOLOGICAL  DIAGNOSIS 

lesions  may  be  detected.  Inspection  of  the  cervix  aside  from  the  mere 
question  of  cervical  diseases  gives  evidence  concerning  the  parity  of 
the  woman  and  the  probability  of  a  chronic  gonorrheal  infection. 

Palpation. — ^Evidence  of  gonorrheal  infection  may  be  shown  by 
"milking"  Skene's  tubules  and  the  vulvovaginal  glands.  The  friability 
and  the  induration  of  a  cancerous  growth,  the  peculiar  disk-like  hard- 
ness of  a  chancre,  the  fluctuation  of  a  vulvovaginal  cyst,  or  the  tender- 
ness and  induration  of  an  inflammatory  affection  may  be  noted.  The 
condition  of  the  perineal  floor,  the  presence  of  cystocele  and  rectocele, 
and  the  spastic  contraction  encountered  in  cases  of  vaginismus  may 
be  detected.  The  friability  of  a  cervical  outgrowth,  softening  or  indu- 
ration of  the  cervix,  or  an  abnormality  in  the  diameter  of  the  cervical 
canal — all  may  be  quickly  ascertained. 

Palpation  of  the  vaginal  vault  yields  further  information.  In  front  of 
the  cervix  the  sharp  kink  of  an  anteflexion  may  be  recognized;  the  body 
of  the  uterus  may  be  felt  through  the  posterior  vaginal  fornix  in  well- 
marked  cases  of  retroposition  and  often  also  an  angle  of  flexion  between 
the  cervix  and  the  body.  An  ovary  prolapsed  into  Douglas'  pouch  is 
at  once  detected. 

While  this  simple  digital  examination  gives  a  considerable  amount  of 
information,  no  examination  is  complete  without  bimanual  palpation. 
By  this  means  the  pelvic  organs  are  picked  up  between  the  palpating 
hands  one  after  the  other,  and  an  estimate  is  made  of  their  size,  mobility, 
consistency,  and  sensitiveness.  The  feasibility  of  a  satisfactory  bimanual 
palpation  in  a  given  case  will  depend  upon  the  degree  of  relaxation  of 
the  abdominal  muscles  which  the  patient  is  able  to  induce  voluntarily, 
and  upon  the  amount  of  adipose  tissue  in  the  abdominal  walls.  Rigid 
or  thick  abdominal  parietes  render  bimanual  examination  difficult  or 
unsatisfactory  unless  an  anesthetic  is  employed. 

In  bimanual  palpation  the  palmar  surface  of  one  hand  is  placed 
upon  the  abdominal  wall  and  one  or  two  fingers  of  the  other  hand  are 
introduced  into  the  vagina  or  into  the  rectum.  Palpation  is  made  first 
with  the  organs  in  the  position  in  which  they  are  found.  Afterward, 
except  in  acute  or  subacute  pelvic  inflammatory  disease,  if  it  is  desir- 
able, bimanual  palpation  may  be  made  with  a  finger  in  the  rectum 
while  the  uterus  is  drawn  downward  by  means  of  a  tenaculum.  This 
maneuver  brings  the  entire  posterior  surface  of  the  uterus  within  reach 
of  the  examining  finger  and  permits  a  minute  examination  of  the  pos- 
terior surface  of  the  broad  ligaments  and  of  the  pouch  of  Douglas. 

In  bimanual  palpation  the  cervix  is  located  with  the  vaginal  finger 
and  the  direction  of  its  axis  in  relation  to  that  of  the  vagina  is  noted. 
Normally  it  is  almost  at  a  right  angle  and  points  toward  the  coccyx. 
If  it  is  found  in  the  axis  of  the  vagina  it  is  quite  likely  that  the  uterus 
is  retroposed  or  that  the  patient  is  suffering  from  an  acute  anteflexion 
of  the  cervix.  The  body  of  the  uterus  is  the  next  objective  point.  If 
it  is  in  normal  position — anteversion  and  anteflexion — it  may  be  pal- 
pated between  the  vaginal  finger  placed  upon  the  anterior  vaginal  wall 
just  in  front  of  the  cervix,  and  the  abdominal  hand  pressed  downward 


METHODS  OF  EXAMINATION  705 

and  toward  die  pelvic  outlet  in  the  median  line  above  the  symphysis. 
If  the  fundus  is  not  found  by  this  maneuver,  it  is  evidently  out  of  posi- 
tion. The  vaginal  finger  is  nov^  carried  back  of  the  cervix  along  the 
posterior  vaginal  vault  while  the  abdominal  hand  is  sunk  downward 
below  the  sacral  promontory.  In  case  of  well-marked  retroposition,  the 
posterior  surface  of  the  body  of  the  uterus  will  be  felt  inclining  back- 
ward toward  the  sacrum,  and,  if  retroflexion  is  present,  the  angle 
between  the  cervix  and  the  body  can  be  made  out  easily.  Besides  the 
position,  the  size,  consistency,  mobility,  shape,  and  sensitiveness  of 
the  uterus  may  be  determined. 

To  palpate  the  left  adnexa,  the  vaginal  finger  is  carried  to  the  extreme 
left  lateral  part  of  the  vaginal  fornix,  and  pressed  upward  along  the 
pelvic  wall  as  far  as  possible  while  the  abdominal  hand  is  gently  sunk 
downward  and  forward  over  the  brim  of  the  true  pelvis  to  the  left  of 
the  sacral  promontory.  The  finger  in  the  vagina  and  the  fingers  of 
the  abdominal  hand  are  approximated  at  the  highest  lateral  and  pos- 
terior position  feasible  and  then  drawn  gently  forward.  By  this  means 
the  normal  ovary  and  tube  are  brought  between  the  fingers.  The 
normal  ovary  feels  like  a  smooth,  elliptical  body,  about  the  size  of  an 
almond,  which  slips  or  jumps  away  and  is  freely  movable.  The  normal 
tube  is  difficult  to  palpate,  giving  the  impression  of  a  very  soft  rubber 
tube  about  the  diameter  of  a  lead  pencil.  The  examiner  can  be  sure 
only  in  very  exceptional  cases  that  the  tube  is  felt.  Muscular  strands 
in  the  abdominal  wall,  or  the  round  ligament,  will  often  be  mistaken 
for  a  normal  tube.  The  right  adnexa  may  be  palpated  by  similar 
maneuvers  on  the  opposite  side. 

In  the  case  of  an  adherent  ovary  the  organ  will  be  immovable  and 
somewhat  enlarged,  and  will  feel  as  if  it  were  stuck  to  the  pelvic  wall 
or  floor.  If  the  tube  and  the  ovary  are  enlarged  and  adherent,  they 
form  an  irregular,  retort-shaped  mass  in  which  it  is  difficult  to  distin- 
guish one  organ  from  the  other. 

It  is  to  be  remembered  that  the  position  of  the  uterus  will  influence 
the  position  of  the  ovary.  Thus,  if  the  uterus  is  retroposed  or  in  de- 
scensus, the  ovary  will  be  nearer  the  median  line  and  lower;  when  the 
uterus  is  in  the  normal  position,  it  is  higher  and  more  laterally  placed. 
When  the  ovary  is  prolapsed,  it  may  be  felt  by  turning  the  palmar  sur- 
face of  the  finger  backward  and  palpating  Douglas'  cul-de-sac  by 
pushing  backward  and  outward.  The  ovary  will  be  recognized  as  a 
smooth,  elliptical  body  which  slips  away  from  the  examining  finger. 
A  scybalous  mass  in  the  rectum  gives  a  sensation  to  the  finger  very  like 
a  prolapsed  ovary,  but  it  may  be  excluded  by  noting  that  it  pits  on 
pressure  or  by  making  an  examination  per  rectum. 

Bimanual  rectal  palpation,  with  the  uterus  drawn  downward  by  means 
of  a  tenaculum,  is  a  most  valuable  means  of  diagnosis  in  affections  of 
the  tubes  and  ovaries.  The  finger  is  inserted  into  the  rectum  and  pushed 
backward  and  downward  until  it  passes  between  the  utero-sacral  liga- 
ments; it  is  then  turned  upward  upon  the  posterior  surface  of  the  uterus 
and  to  either  side  upon  the  posterior  surface  of  the  broad  ligaments. 
45 


706  GYNECOLOGICAL  DIAGNOSIS 

In  the  case  of  inflammatorj  affections  of  the  ovaries  and  tubes  irreg- 
ular masses  will  be  felt  back  of  the  uterus  on  one  or  on  both  sides, 
displacing  it  forward.  When  an  inflammatory  affection  involves  the 
cellular  tissue  of  the  broad  ligaments,  the  induration  felt  at  the  vaginal 
vault  is  very  dense  and  board-like  and  extends  all  the  way  to  the  pelvic 
wall  and  fuses  with  it. 

Pelvic  masses,  without  induration  of  the  vaginal  fornices  or  the 
bases  of  the  broad  ligaments,  are  usually  uterine  or  ovarian  in  origin — 
uterine,  if  they  are  in  connection  or  move  with  the  uterus;  ovarian,  if 
they  are  distinctly  separate  from  the  uterus  and  independently  movable. 
Induration  of  the  broad  ligaments  or  the  vaginal  fornices  with  immo- 
bility or  partial  fixation  of  the  uterus,  is  suggestive  of  inflammatory 
disease  involving  the  tubes  and  the  pelvic  peritoneum,  possibly  also  of 
carcinoma  with  extension  to  the  broad  ligament,  or  of  cellulitis.  Pelvic 
enlargements  rising  slightly  above  the  pelvic  brim  and  decidedly  lateral 
in  position  are  apt  to  be  inflammatory  in  type.  Those  which  have  a 
more  or  less  median  position  and  extend  well  into  the  abdominal  cavity 
are  usually  newgrowths  of  the  uterus  or  of  the  ovaries. 

Abdominal  Examination. — Inspection. — ^The  color  of  the  skin,  the 
presence  of  dilated  veins,  the  contour  of  the  abdomen,  the  linese 
albicantes,  and  the  linea  nigra  are  determined  by  inspection.  The 
abdominal  respiratory  wave  and  the  presence  of  any  abdominal  enlarge- 
ment are  noted.  The  abdomen  should  be  inspected  from  the  side,  from 
the  feet,  and  from  the  head  of  the  patient.  In  the  presence  of  an  ab- 
dominal tumor  it  should  be  observed  whether  the  enlargement  involves 
the  entire  abdomen  or  is  confined  to  the  lower  part ;  whether  the  enlarge- 
ment has  a  median  or  a  lateral  position,  and  whether  its  surface  is  even 
or  irregular. 

Palpation. — Palpation  verifies  inspection  as  to  the  shape  and  the 
contour  of  the  abdomen.  It  also  confirms  the  situation  as  well  as  the 
regularity  of  surface  of  any  abdominal  enlargement  which  has  been 
observed.  Palpation  also  in  addition  discovers  rigidity  and  tenderness 
and,  combined  with  percussion,  the  physical  sign  of  fluctuation.  The 
tonicity  of  the  abdominal  wall  may  be  determined  by  palpation. 
Diastasis  of  the  recti  muscles  may  be  estimated  by  sinking  the  fingers 
between  them  while  the  patient  tries  to  raise  herself  into  a  sitting  posi- 
tion. By  palpation  it  can  be  ascertained  whether  an  abdominal  tumor 
is  of  pelvic  origin.  If  the  fingers  can  be  dipped  down  between  the  tumor 
and  the  symphysis  pubis,  the  tumor  is  probably  not  pelvic.  In  pelvic 
growths  this  maneuver  meets  with  firm  resistance. 

In  making  palpation  the  hands  should  be  thoroughly  warmed,  the 
palmar  surface  should  be  pressed  gently  against  the  abdominal  wall, 
making  deeper  pressure  with  the  fingers  as  the  patient's  confidence  is 
gained  and  the  abdominal  wall  relaxes.  In  eliciting  fluctuation  it  may 
be  advantageous  to  have  an  assistant  place  the  ulnar  border  of  the  hand 
in  the  median  line  of  the  abdomen  or  somewhere  at  least  on  the  surface 
between  the  palpating  and  the  percussing  hand.  In  this  way  the  spur- 
ious fluctuation  due  to  an  accumulation  of  fat  in  the  abdominal  parietes 
may  be  eliminated. 


THE  VULVA  707 

Information  concerning  the  consistency  of  an  abdominal  enlarge- 
ment, whether  it  is  hard  or  soft,  elastic  or  doughy,  may  also  be  gained 
by  palpation. 

Percussion. — ^All  tumors  of  the  abdomen  originating  in  the  pelvis  are 
dull  on  percussion.  The  area  of  dulness  begins  below  at  the  pelvic 
brim  and  is  most  pronounced  over  the  greater  bulge  or  convexity  of  the 
tumor.  Surrounding  it  above  and  at  the  sides  there  is  resonance  or 
tympany  (coronal  resonance).  The  percussion  note  changes  with  the 
the  position  of  the  patient  when  there  is  a  free  intraperitoneal  collection 
of  fluid.  The  percussion  note  over  a  tumor  or  over  an  encysted  col- 
lection of  fluid  is  little  affected  by  position. 

Auscultation. — ^Auscultation  is  of  service  almost  solely  in  distinguishing 
the  fetal  heart  sounds  and  the  placental  bruit. 

THE  VULVA. 

Malformation. — Malformations  of  the  vulva  include: 

Atresia  of  the  urethra  or  the  vagina. 

Persistent  Cloaca. — ^The  anus  opens  into  the  vestibule;  there  is  no 
perineum. 

Hypospadias. — ^A  congenital  vesicovaginal  fistula. 

Epispadias. — Usually  accompanied  by  fissure  of  the  clitoris,  and  some- 
times also  of  the  symphysis  and  the  entire  anterior  vesical  wall. 

Infantile  Vulva. — General  absence  of  development  of  the  labia  majora 
and  minora. 

Hermaphrodism. 

Imperforate  hymen. 

Rigidity  and  thickness  of  the  hymen. 

Inflammations. — Vulvitis. — Causes. — Vulvitis  is  caused  in  the  young 
by  epidemic  gonorrheal  infection  as  seen  in  children's  homes  and 
hospitals,  or  by  gonorrheal  infection  from  the  mother  or  the  nurse, 
or  through  the  medium  of  napkins,  towels,  etc.  Thread-worms  and 
uncleanliness  may  be  factors  in  the  vulvitis  of  children.  In  the  adult, 
repeated  gonorrheal  infection  from  more  or  less  constant  bathing  of  the 
part  with  gonorrheal  pus,  irritating  discharge  from  a  vesical  fistula,  or 
an  ulcerating  carcinoma,  diabetic  urine,  too  frequent  sexual  inter- 
course, or  masturbation  may  produce  it.  Streptococcus  or  diphtheritic 
infection  of  the  vulva  may  occur  in  puerperal  women.  The  rectal 
discharge  in  typhus  fever  and  in  dysentery  may  excite  vulvitis. 

Symptoms. — Pain,  which  varies  between  a  sense  of  discomfort  or 
itching  and  a  severe  burning;  difficulty  in  walking;  leucorrhea. 

Examination. — The  vulva  is  covered  with  a  mucopurulent  or  purulent 
discharge.  After  this  has  been  wiped  or  washed  away,  the  vulvar  mucosa 
is  seen  to  be  swollen,  reddened,  and  edematous.  In  the  gonorrheal 
vulvitis  of  children  the  vagina  is  usually  coincidently  affected.  In 
adults,  the  urethra  and  the  vulvovaginal  glands,  and  often  the  cervix, 
are  involved.  The  sebaceous  glands  of  the  labia  majora  and  the  labia 
minora  may  be  inflamed,  the  lesions  resembling  those  of  acne  (follicular 


708  GYNECOLOGICAL  DIAGNOSIS 

vulvitis),  and  the  vulvar  mucosa  between  the  follicles  appearing  normal, 
or  at  most  but  slightly  reddened.  To  determine  the  type  of  infection 
smears  and  cultures  should  be  made,  in  cases  of  vulvitis,  from  the  dis- 
charge covering  the  surface  of  the  vulva,  the  vulvovaginal  glands,  and 
Skene's  tubules.  In  the  adult,  simultaneous  infection  of  Skene's  tubules, 
the  vulvovaginal  glands,  and  the  cervix  is  almost  always  gonorrheal. 

Pruritus  Vulvae. — Causes. — Pruritus  vulvae  is  either  a  pure  neurosis 
or  a  symptom  produced  by  the  irritation  of  substances  circulating  in 
the  blood  (bile,  uric  acid,  urea,  sugar,  morphine,  alcohol,  or  iodine); 
congestion  or  venous  stasis  of  the  vulva  (heart  disease,  pregnancy, 
retroposition  of  the  uterus,  or  uterine  tumors);  skin  diseases  (erythema, 
urticaria,  herpes,  eczema);  carcinoma  of  the  vulva  (early  symptom); 
irritating  discharges  (hyperidrosis,  diabetic  urine,  ammoniacal  urine, 
leucorrhea  from  gonorrheal  infection  of  the  cervix  or  the  uterus,  carci- 
noma or  decomposing  fibroid  tumor);  rectal  discharge  (purulent  and 
catarrhal  inflammation  of  the  rectum);  parasites,  animal  (pediculi, 
oxyuris  vermicularis)  and  vegetable  (leptothrix,  leptomitus,  oidium 
albicans);  heat  (pruritus  estivalis)  and  cold  (pruritus  hiemalis),  or  by 
masturbation. 

Symptoms. — Intense  itching  of  the  vulva,  worse  at  night  and  under 
the  influence  of  warmth  and  exercise;  worse  also  during  pregnancy  and 
during  the  menstrual  periods.  Because  of  an  uncontrollable  desire  to 
scratch,  the  patient  avoids  society  and  becomes  depressed  and  nervous. 
Relief  may  be  sought  in  drugs. 

Examination. — The  vulvar  surface  usually  shows  one  of  the  local 
conditions  noted  above.  The  presence  of  scratch  marks  is  noted  upon 
the  skin.  In  old  cases  there  is  considerable  thickening  of  the  vulvar  skin 
which  becomes  leathery  and  has  a  dead  white  surface  broken  here  and 
there  by  the  excoriations  made  by  the  patient's  finger  nails.  Urinalysis 
may  discover  sugar,  bile,  or  an  excess  of  uric  acid.  In  every  case  of 
pruritus  it  is  very  important  to  determine  the  underlying  lesion.  In  the 
few  instances  where  none  of  the  causes  already  mentioned  are  found 
the  disease  may  be  regarded  as  a  pure  neurosis. 

Kraurosis  Vulvae. — ^A  very  rare  condition  characterized  by  an  atrophy 
and  a  shrinkage  of  the  vulvar  parts. 

Adhesions  of  the  prepuce  to  the  glans  clitoris  is  a  common  condition 
which  produces  irritation  only  when  an  accumulation  of  smegma  occurs 
behind  them. 

Elephantiasis  of  the  Vulva.- — Cause. — Syphilis  is  the  usual  cause  in 
this  country.  Symptoms  are  due  to  mechanical  irritation,  and  there  is 
inconvenience  in  walking  or  in  sexual  intercourse. 

Examination. — ^There  is  hypertrophy  of  the  labia  majora  and  minora; 
the  parts  are  indurated  and  sometimes  edematous.  Excoriations  or 
warty  outgrowths  may  appear  upon  the  surface. 

Venereal  Sores. — The  venereal  lesions  in  the  female  differ  slightly 
from  those  in  the  male.  Neither  the  chancre  nor  the  chancroid  is  so 
constant  in  form.  The  appearance  of  each  is  modified  by  the  personal 
cleanliness  of  the  woman,  by  her  habits,  by  bruising  of  the  vulvar  parts 


THE  VULVA  709 

at  the  time  when  infection  occurs,  and  by  the  chemical  and  mechanical 
irritation  of  strong  disinfecting  solutions  which  are  sometimes  used 
before  a  physician  is  consulted.  For  this  reason,  edema  and  induration 
of  the  labia  majora  are  not  infrequent  in  association  with  venereal  lesions. 

Chancre. — For  a  description  of  the  chancre  see  p.  643.  It  is  not  so 
often  observed  in  the  female.  The  lesion  occurs  upon  the  vulva  or 
the  cervix  and  commonly  takes  the  form  of  the  indurated  papule.  It 
is  said  to  be  multiple  sometimes.  The  diagnosis  is  confirmed  by 
indentification  of  the  treponema  (spirocheta)  pallidum  in  suitably  stained 
preparations. 

Chancroid. — Chancroid  in  the  female  resembles  the  same  sore  in  the 
male  (see  p.  645). 

Herpes  Vulvae. — Herpes  vulvae  resembles  herpes  preputialis  (see  p.  643). 

Secondary  syphilitic  lesions  of  the  vulva  occur  quite  frequently.  A 
papular  syphilide  developing  upon  the  vulva  often  has  an  abraded  and 
secreting  surface,  and  is  partly  or  completely  covered  by  a  gray,  adher- 
ent, offensive  pseudomembrane.  This  is  a  mucous  patch.  Sometimes  the 
moist  papule  takes  on  a  distinct  papillary  overgrowth  (condyloma). 
Condylomata  appear  as  raised,  flat,  raw  surfaces;  the  cellular  infiltra- 
tion is  so  abundant  that  the  papillary  nature  of  the  growth  is  but  imper- 
fectly marked  and  may  be  observed  only  after  careful  inspection.  When 
the  mucous  patch  preceding  the  condyloma  has  developed  from  a  large 
papular  syphilide,  the  elevated  surface  varies  in  size  from  a  shirt  button 
to  a  penny. 

Tertiary  syphilitic  lesions  of  the  vulva  are  rare.  Gumma  of  the  labia 
majora  is  the  usual  lesion;  it  shows  a  tendency  to  break  down  and 
suppurate. 

Venereal  Warts. — Causes. — ^Venereal  warts  result  from  the  irritation 
of  un cleanliness  or  from  the  irritation  of  gonorrheal  pus.  They  are 
also  associated  at  times  with  secondary  syphilitic  lesions. 

Symptoms. — Their  symptoms  vary  between  actual  discomfort  and 
pain.  Usually  they  simply  interfere  mechanically  with  walking  or  inter- 
course. When  inflamed,  they  are  painful.  They  sometimes  have  a 
thin  and  highly  irritating  discharge. 

Examination. — ^Venereal  warts  appear  as  papillary  excrescences,  either 
in  a  single  discrete  group  or  in  a  coalescent  cauliflower-like  mass.  They 
may  occur  on  the  vulva,  mons  veneris,  perineum,  or  anus.  They  are 
also  occasionally  found  on  the  vagina  and  upon  the  cervix.  They 
usually  have  a  purplish  red  color;  the  surface  is  moist  and  divided  into 
small  projections  which  have  pointed  ends  (condyloma  acuminatum). 

Enlargements  and  Tumors  of  the  Vulva. — Varicose  Veins  of  the 
Vulva. — Causes. — ^Pregnancy,  pelvic  exudates,  pelvic  tumors,  retro- 
position  of  the  uterus  with  adhesions,  straining  at  stool,  prolonged 
standing,  and  heavy  work  are  causes.  They  are  usually  found  in  the 
labia  majora;  the  other  parts  and  the  vagina  may  be  involved. 

Symptoms. — Itching  and  burning,  or  a  sense  of  discomfort  or  of  weight. 

Examination. — An  elongated,  knotty,  bluish  enlargement  is  found 
made  up  of  dilated  and  tortuous  veins.     Upon  palpation  they  resemble 


710 


GYNECOLOGICAL  DIAGNOSIS 


a  bundle  of  earth-worms.  The  condition  varies  from  a  slight  distention 
of  the  vulvar  veins  to  a  tumor  as  large  as  the  fetal  head. 

Hematoma  of  the  vulva  is  caused  by  the  subcutaneous  rupture  of  vari- 
cose veins  during  pregnancy  or  labor,  or  as  the  result  of  a  fall  or  of  a 
blow. 

Symptoms. — Sudden  pain  in  the  affected  part,  with  rectal  or  vesical 
tenesmus.  Later  there  is  also  a  feeling  of  fulness,  and,  if  suppuration 
occurs,  the  signs  of  abscess. 

Examination  shows  a  purplish  globular  tumor  which  may  be  as  large 
as  the  fetal  head.     It  is  tense  and  elastic  at  first,  but  later  doughy. 


Fig.  437 


Fig.  438 


Early  carcinoma  of  the  vulva,  confined  to  the 
clitoris. 


Early  adenocarcinojna  of  the  vulva,  limited 
.  to  the  left  lesser  labium.     (Hurdon). 


Carcinoma  of  the  Vulva. — Causes. — Primary  carcinoma  is  usually  of 
the  squamous  type  (epithelioma),  and  may  be  preceded  by  psoriasis, 
papillomata,  or  some  trauma.  There  may  be  no  preceding  lesion. 
Secondary  carcinoma  results  from  carcinoma  higher  in  the  genital  tract, 
and  may  be  of  the  cylinder-cell  variety  (adenocarcinoma).  The  growth 
begins  in  the  sulcus  between  the  labium  ma  jus  and  the  nympha,  or  upon 
the  clitoris  or  in  the  urethra.  It  occurs  in  subjects  between  the  ages  of 
forty  and  sixty  years,  rarely  in  the  young  (one  case  aged  twenty-three). 

Symptoms.- — ^Pruritus  is  the  most  common  early  symptom,  but  is  not 
characteristic.  There  may  be  no  early  subjective  symptoms.  Later, 
when  ulceration  has  occurred,  pain  is  more  or  less  constant  and  severe. 
The  inguinal  glands  on  the  affected  side  become  enlarged.     There  is  a 


THE  VULVA 


711 


foul-smelling  discharge  and  slight  hemorrhage.     General  ill-health  and 
cachexia  supervene. 

Examination.- — The  affection  first  appears  as  a  small,  indurated, 
elevated  nodule.  Later,  ulceration  occurs.  The  edge  of  the  ulcer  is 
elevated,  hard,  and  bluish  red.  The  surface  is  granular  and  is  covered 
by  a  semi-opaque  putrid  secretion.  Little  "maggot-like"  bodies  can 
often  be  pressed  out  of  the  floor  of  the  ulcer.  They  are  epithelial 
pearls,  or  nests,  and  are  highly  diagnostic  of  squamous  carcinoma  or 
epithelioma.    The  labium  surrounding  the  carcinomatous  ulcer  becomes 


Fig.  439 


Epithelioma  of  the  vulva  (labium  majus).  Indurated  fungoid  ulcer.  Slight  trauma  causes 
free  bloody  oozing.  Enlarged  right  inguinal  lymphatic  glands.  Diagnosis  made  by  microscope. 
(Carnett). 


thickened  and  indurated.  The  opposing  surfaces  of  the  vulva  may 
develop  a  carcinomatous  growth  from  contact. 

Differential  Diagnosis. — It  is  important  to  diagnose  the  condition  in  its 
earliest  stage.  To  this  end  any  suspected  lesion  should  be  immediately 
excised  and  submitted  to  microscopic  examination. 

Lupus  appears  at  a  younger  age.  The  affection  progresses  very  slowly 
and  there  is  little  pain.  Instead  of  single  hard  nodules,  there  are  mul- 
tiple soft  nodules.  The  discharge  is  not  putrid.  The  ulceration  tends 
to  undergo  cicatrization.  Healthy  skin  is  frequently  found  between 
neighboring  lesions.     The  inguinal  glands  are  not  involved,  as  a  rule. 


712  GYNECOLOGICAL  DIAGNOSIS 

Chancre. — There  is  a  history  of  infection  and  a  period  of  incubation. 
The  sore  develops  rapidly,  is  not  painful,  and  does  not  spread;  there 
is  a  thin,  scanty,  sanious  discharge.  The  inguinal  glands  enlarge  early 
and  constitutional  symptoms  appear. 

Chancroids. — ^There  is  a  history  of  contagion  and  a  short  period  of 
incubation.  The  lesions  are  multiple  and  inflammatory;  they  spread 
rapidly  and  are  auto-inoculable.  Inguinal  enlargement  is  early  and  per- 
haps unilateral. 

Venereal  Warts. — ^Unless  the  diagnosis  is  plain,  the  growths  should  be 
excised  and  examined  microscopically.  It  should  be  remembered  that 
papillomata  may  become  cancerous. 

Sarcoma  of  the  vulva  usually  affects  the  labia  majora.  It  begins  as  a 
hard,  round  nodule,  brown  or  black  in  color.  It  grows  rapidly;  ulcera- 
tion occurs  late.  The  inguinal  glands  are  involved  late.  The  disease 
is  usually  fatal.     Death  occurs  from  metastasis  through  the  veins. 

Lupus  of  the  vulva  is  rare.  The  lesion  is  produced  by  the  tubercle 
bacillus,  and  consists  early  of  nodules  varying  in  size  from  a  pinhead  to 
a  bean,  embedded  rather  deeply  in  the  skin;  the  nodules  have  a  reddish, 
brownish,  or  a  yellowish  red  color.  Later,  these  become  larger  and 
undergo  cheesy  or  colloid  degeneration.  Ulceration  finally  takes 
place.  The  ulcers  are  soft  and  usually  superficial;  they  may  be  deep, 
causing  a  fistulous  communication  between  the  vagina  and  the  sur- 
rounding parts.  The  ulcerations  have  bright  red  granulations,  they 
bleed  easily,  and  are  covered  with  pus  which  does  not  have  a  bad  odor. 
Cicatrization  occurs  irregularly  and  may  produce  stricture  or  stenosis 
of  the  urethra,  vagina,  or  rectum.  There  is  a  general  increase  of  con- 
nective tissue  in  the  affected  parts,  sometimes  resembling  elephantiasis. 
There  is  little  pain  and  the  growth  is  very  slow. 

Fibromyoma  of  the  vulva  affects  the  labia  majora  principally  and  has 
the  same  structural  features  as  fibromyoma  elsewhere.  The  symptoms 
are  the  result  of  mechanical  interference.     The  condition  is  very  rare. 

Lipoma  of  the  vulva  affects  the  labia  majora  or  the  nlons  veneris  and 
resembles  lipomatous  tumors  found  in  other  parts. 


THE  VULVOVAGINAL  GLANDS. 

Inflammation  of  the  ducts  of  the  vulvovaginal  glands  is  usually  the 
result  of  gonorrhea.  Other  infections  extending  from  the  surface  may 
cause  it.  In  gonorrheal  inflammation  of  the  duct  the  orifice  is  sur- 
rounded by  a  red,  slightly  elevated  spot,  known  as  the  gonorrheal  macule. 
Pressure  over  the  course  of  the  duct  will  express  a  drop  of  pus.  Inflam- 
mation of  the  ducts  of  the  vulvovaginal  glands  may  lead  to  a  retention 
cyst  or  to  an  extension  of  the  infection  to  the  gland  substance  with  the 
production  of  an  abscess. 

Abscess  of  the  vulvovaginal  gland  is  evidenced  by  severe  pain  and 
marked  swelling  and  edema  of  the  surrounding  parts.  The  swelling 
may  extend  even  to  the  anus.    Fluctuation  appears  first  upon  the  inner 


THE  VAGINA  713 

surface  of  the  labium,  and,  if  the  pus  is  not  evacuated  by  an  incision,  it 
finally  finds  exit  through  several  fistulous  openings  below  the  orifice  of 
the  duct.     These  may  keep  on  discharging  indefinitely. 

Cyst  of  the  vulvovaginal  glands  results  either  from  an  occlusion  of  the 
duct  by  an  inflammatory  process  or  from  thickening  of  the  glandular 
secretion.  The  symptoms  produced  by  vulvovaginal  cysts  are  usually 
the  result  of  mechanical  interference  with  sitting,  walking,  or  sexual 
congress. 

Examination. — Vulvovaginal  cysts  vary  in  size  from  that  of  a  walnut 
to  a  tumor  as  large  as  a  child's  head.  When  as  large  as  an  egg  or  over, 
the  mucosa  to  the  inner  side  of  the  labium,  overlying  the  surface  of  the 
cyst,  is  considerably  thinned.  The  cyst  contents  are  clear  and  colorless, 
or  yellow,  or  a  turbid,  chocolate  color  from  admixture  with  blood. 
Vulvovaginal  cysts  must  be  distinguished  from  inguinal  hernia,  hydrocele 
of  the  canal  of  Nuck,  and  cysts  of  old  hernial  sacs.  In  them  the 
enlargement  is  more  to  the  upper  and  outer  part  of  the  labium  majus, 
and  is  connected  with  the  external  inguinal  ring. 


THE  VAGINA. 

Malformations  of  the  Vagina. — Vaginal  Septa. — Vaginal  septa  usually 
extend  upward  from  the  vulva  and  divide  the  vagina  into  two  passages, 
seldom  of  equal  size.  Both  of  the  divisions  may  communicate  with  the 
uterus  or  one  of  them  may  end  blindly.  Various  malformations  of  the 
uterus  may  be  associated  with  vaginal  septa. 

Hematocolpos. — The  hymen  is  imperforate  and  the  vagina  is  dis- 
tended with  an  accumulation  of  the  menstrual  fluid.  The  condition 
does  not  arise  until  after  the  onset  of  puberty.  The  menstrual  molimina 
develop,  but  the  flow  does  not  appear. 

Atresia  of  the  vagina  may  be  the  result  of  adhesive  inflammations 
occurring  before  birth  (congenital  atresia)  or  during  early  life. 

Complete  absence  of  the  vagina  is  a  very  rare  condition  and  is  usually 
associated  with  an  absence  or  a  defective  development  of  the  uterus, 
tubes,  and  ovaries. 

Inflammations. — Vaginitis. — ^Vaginitis  is  usually  subacute  or  chronic, 
except  in  children.  It  depends  in  the  adult  upon  repeated  infection 
plus  a  mechanical  irritation  or  injury,  or  upon  some  general  condi- 
tion which  lowers  the  vitality  of  the  vaginal  mucosa.  Predisposing 
causes  are  venous  stasis,  the  hyperemia  incident  to  pregnancy,  small 
abrasions  of  the  mucosa,  and  the  irritation  of  foreign  bodies.  An  irri- 
tating gonorrheal  discharge  from  the  cervix  is  the  most  frequent  cause. 
Vaginitis  occurs  in  connection  with  vesicovaginal  fistula  and  sometimes 
also  with  the  exanthemata.  Dysenteric  discharges,  caustic  solutions, 
the  streptococcus  and  the  diphtheria  baciflus  may  produce  it. 

Examination. — In  acute  vaginitis  the  vaginal  walls  are  red,  swollen,  hot, 
and  very  tender.  They  are  covered  with  a  mucopurulent  or  a  purulent 
discharge.     The  entire  extent  of  the  vagina  is  not  involved  usually  except 


714  GYNECOLOGICAL  DIAGNOSIS 

in  children.     The  vulva  is  bathed  in   the  discharge,  which  becomes 
highly  offensive. 

In  subacute  or  in  chronic  vaginitis  the  vaginal  surface  shows 
numerous  small  red  spots;  these  are  caused  by  inflammatory  infiltra- 
tion of  the  papillae  in  the  vaginal  mucosa.  The  overlying  epithelium 
subsequently  desquamates  and  small  eroded  areas  are  formed.  In 
old  persons  such  areas,  when  they  are  apposed,  may  adhere.  The 
vaginal  walls  are  covered  with  a  thinner  and  a  less  purulent  discharge 
than  in  the  acute  form.  In  old  chronic  cases  the  lesion  may  be  con- 
fined to  eroded  patches  in  the  vaginal  vault.  In  children  the  local 
examination  should  be  confined  to  an  inspection  of  the  vaginal  orifice 
or  to  the  introduction  of  a  small  Kelly  cystoscope  into  the  vagina.  The 
examination  of  the  vagina  in  the  adult  is  preferably  made  by  means  of 
a  Sims  speculum,  with  the  patient  in  the  Sims  or  the  knee-chest  position. 

Tumors. — Vaginal  Cysts. — Vaginal  cysts  are  the  most  frequent  of  the 
vaginal  tumors,  but,  even  so,  they  are  rare.  They  result  from  the  dis- 
tention of  aberrant  vaginal  glands,  inclusion  of  epithelium  following 
operations,  hematoma,  dilatation  of  a  lymph  vessel,  and  the  echino- 
coccus.  Dermoid  cysts  are  found  rarely.  Cysts  may  also  arise  from 
rests  of  the  Wolffian  duct  in  the  upper  part  of  the  vaginal  vault.  Such 
cysts  are  often  multiple  and  occur  in  a  row.  Vaginal  cysts  are  hemi- 
spherical or  ovoid  and  project  more  or  less  into  the  vagina.  Rarely 
they  may  be  pedunculated.  The  overlying  mucosa  is  thinned  out. 
The  contents  of  a  cyst  may  be  clear,  thin,  and  watery,  or  gluey  and 
opalescent,  or  chocolate  colored. 

The  symptoms  are  nil  when  the  tumor  is  small.  When  large,  there 
is  interference  with  urination  and  defecation.  The  tumor  may  form 
an  obstruction  to  intercourse  or  to  labor.  There  may  be  a  fetid  leucor- 
rhea  if  the  passage  of  the  menstrual  fluid  is  obstructed  and  an  accumu- 
lation occurs  above  the  tumor.  The  condition  must  be  distinguished 
from  cystocele,  rectocele,  and  suburethral  abscess. 

Fibromyoma  of  the  vagina  is  an  infrequent  form  of  vaginal  tumor. 
It  has  the  same  peculiarities  as  fibromyoma  elsewhere. 

Sarcoma  of  the  vagina  is  very  rare.  In  adults  it  forms  a  diffuse  growth 
which  may  be  situated  in  any  part  of  the  canal.  In  young  children  it  is 
polypoid  or  grape-like  in  form  and  springs  from  the  anterior  vaginal  wall. 

Carcinoma  of  the  Vagina. — ^Primary  cancer  is  very  rare.  Cancer  of 
the  vagina  is  usually  secondary  to  a  growth  higher  in  the  genital  tract. 

Rectovaginal  fistula  in  the  upper  part  of  the  vagina  is  usually  pro- 
duced by  carcinoma;  in  the  lower  part  by  ulcerative  processes  of  a 
tuberculous  or  a  syphilitic  nature  or  by  the  failure  of  operation  for  a 
complete  tear. 

THE  PELVIC  FLOOR. 

Recent  tears  of  the  perineum  belong  to  the  subject  of  obstetrics  and 
will  not  be  discussed  here. 

Relaxation  of  the  pelvic  floor  is  the  result  of  an  injury  to  the  levator 
ani  and  other  muscles  incurred  during  childbirth.     The  symptoms  of  a 


THE  CERVIX  715 

relaxed  pelvic  floor  are  a  feeling  of  loss  of  support,  dragging  and  bearing- 
down  sensations  in  the  lower  abdomen,  and  backache.  All  of  the 
symptoms  are  increased  by  exertion  and  are  relieved  by  the  recumbent 
position. 

Examination  should  be  made  with  the  patient  in  the  dorsal  position. 
Scars  may  be  seen  in  one  or  both  vaginal  sulci,  indicating  the  position 
of  previous  tears.  The  perineal  body  may  appear  cleft  in  the  median 
line,  or  to  one  side.  If  the  lacerations  have  been  subcutaneous,  no 
evidence  of  a  previous  tear  of  the  mucous  membranes  will  be  observed. 
Upon  further  inspection,  it  will  be  found  that  the  anal  cleft  is  shallow, 
the  anus  is  prominent,  the  distance  from  the  external  urinary  meatus 
to  the  anus  is  increased,  the  perineal  body  is  low,  the  vaginal  orifice 
is  gaping,  the  anterior  and  the  posterior  walls  are  either  not  in  contact 
or  they  show  the  presence  of  cystocele  and  rectocele.  If  the  woman 
is  directed  to  "bear  down,"  the  anterior  and  the  posterior  vaginal 
walls  protrude.  If  the  vulva  is  pricked,  the  woman  draws  herself 
away;  no  reflex  muscular  action  closing  the  vagina  and  drawing  up 
the  anus  is  observed.  A  relaxed  pelvic  floor  may  be  complicated  by 
cystocele  and  rectocele,  laceration  of  the  cervix,  and  descensus,  retro- 
position,  or  prolapsus  of  the  uterus. 

Rectocele. — A  rectocele  is  a  protrusion  of  the  rectovaginal  septum  in 
the  direction  of  the  vaginal  outlet.  The  patient  may  be  unaware  of  its 
presence,  or  she  may  feel  the  protrusion  at  stool  and  imagine  she  has 
falling  of  the  womb.  She  may  also  experience  difficulty  in  defecation, 
and  may  only  partially  succeed  until  the  rectocele  is  pushed  backward 
and  upward  with  the  finger.  The  condition  may  be  diagnosticated  by 
introducing  a  finger  into  the  rectum  and  directing  it  upward,  when  it 
will  enter  the  most  prominent  part  of  the  rectocele. 

Cystocele. — A  cystocele  is  a  protrusion  of  the  vesicovaginal  septum  in 
the  direction  of  the  vaginal  outlet.  It  causes  difficulty  in  thorough 
evacuation  of  the  bladder;  there  is  usually,  in  bad  cases,  a  certain 
amount  of  residual  urine  which  is  apt  to  decompose  and  produce 
cystitis.  The  tip  of  a  sound  introduced  into  the  bladder  and  turned 
downward  will  enter  the  most  prominent  part  of  the  cystocele. 

THE  CERVIX. 

Malformations. — Double  Cervix. — Two  completely  formed  cervices 
may  occur  with  a  double  uterus  and  a  double  vagina. 

Septate  cervix  may  exist  alone  or  in  connection  with  a  septate  uterus 
or  with  a  uterus  bicornis. 

Infantile  Cervix. — ^The  cervix  is  long  and  conical  with  a  very  small 
external  os;  this  condition  is  apt  to  be  associated  with  a  poorly 
developed  vaginal  vault  and  a  sharply  anteflexed  cervix. 

Pathological  Anteflexion  of  the  Cervix. — ^While  the  cervix  is  nor- 
mally anteflexed  upon  the  uterus,  sometimes  the  condition  is  exaggerated, 
and  it  may  be  associated  also  with  a  conical,  infantile  cervix  and  a 
stenosed   cervical    canal.      Under    these    circumstances    the    condition 


716  GYNECOLOGICAL  DIAGNOSIS 

produces  symptoms  and  the  anteflexion  is  spoken  of  as  pathological. 
The  symptoms  are  dysmenorrhea,  in  which  the  pain  precedes  and  sub- 
sides with  the  establishment  of  the  flow,  and,  in  married  women,  sterility. 
The  diagnosis  is  made  from  the  typical  dysmenorrhea,  and  the  physical 
findings  as  elicited  by  inspection  of  the  cervix,  bimanual  palpation,  and 
the  introduction  of  a  uterine  sound. 

Laceration  of  the  Cervix  and  its  Complications. — Cervical  Lacera- 
tions.— Lacerations  of  the  cervix  result  from  childbirth.  They  may 
be  unilateral,  bilateral,  anterior,  posterior,  or  stellate.  A  lateral  lacera- 
tion is  usually  worse  on  the  left  side. 

Symptoms. — A  cervical  laceration  does  not,  as  a  rule,  give  rise  to 
symptoms  unless  the  laceration  is  complicated  by  eversion,  cystic 
degeneration,  or  hypertrophy  of  the  cervical  lips,  endometritis,  or  sub- 
involution of  the  uterus.  In  the  case  of  an  extensive  tear  into  the  para- 
cervical  connective  tissue,  pelvic  pain  may  be  referred  to  the  scar. 

The  diagnosis  of  a  cervical  laceration  is  made  by  inspection  and  by 
simple  digital  palpation. 

Eversion  of  the  cervical  lips  is  the  result  of  bilateral  laceration  of  the 
cervix.  The  bright  red  cervical  mucosa  is  exposed  to  view.  Because  of 
mechanical  irritation,  the  glands  of  the  exposed  mucosa  secrete  an  excess 
of  cervical  mucus.  The  most  prominent  symptom  is  a  profuse,  thick, 
ropy  discharge.  Sterility  may  ensue  because  of  the  leucorrhea  and  the 
displacement  of  the  external  os.  When  the  cervix  is  actually  inflamed, 
pelvic  pain  may  be  present,  the  result  of  a  complicating  para-uterine 
lymphangitis  or  lymphadenitis.  Other  symptoms  may  be  present  if 
endometritis  or  subinvolution  of  the  uterus  exist. 

Examination. — The  anteroposterior  diameter  of  the  cervix  is  increased. 
The  scars  of  the  lacerations  may  be  felt  as  well  as  the  slightly  irregular 
velvety  surface  of  the  cervical  mucosa;  the  sensation  imparted  to  the  finger 
by  the  latter  is  quite  different  from  the  smooth,  firm  surface  of  the  normal 
cervix.  Inspection  should  be  made  with  the  patient  in  the  Sims  or  in 
the  knee-chest  position.  The  cervix  appears  bright  red  and  granular; 
the  folds  of  the  cervical  mucosa  and  the  lacerations  can  be  plainly  seen. 
There  is  an  abundant  secretion  of  mucus.  By  catching  each  cervical 
lip  with  a  tenaculum  at  the  border  between  the  exposed  cervical  mucosa 
and  the  vaginal  surface  of  the  cervix  and  approximating  them,  the 
normal  relation  of  the  cervical  lips  will  be  restored,  the  everted  mucosa 
will  disappear,  and  the  cervix  will  approach  its  normal  appearance. 

Cystic  Degeneration  of  the  Cervix. — Nabothian  cysts  are  produced  by  an 
occlusion  of  the  ducts  of  the  cervical  glands.  This  results  from  inflam- 
matory processes  following  laceration,  eversion,  or  infection  of  the  cervix. 
The  small  cysts,  varying  in  size  from  a  pinhead  to  a  large  pea  or  bean, 
extend  peripherally  and  appear  on  the  vaginal  surface  of  the  cervix. 
The  entire  cervix  may  be  riddled  with  them,  the  connective  tissue  of 
the  cervix  undergoing  considerable  hypertrophy. 

Symptoms. — There  are  no  distinctive  symptoms.  The  condition  is 
usually  combined  with  the  causal  factors  already  mentioned.  Upon 
examination,  the  cervix  is  found  to  be  hard  and  the  small  cysts  feel 


THE  CERVIX  717 

like  shot  embedded  in  the  cervical  tissue.    Puncture  of  a  cyst  leads  to 
the  escape  of  a  thick,  glairy  mucus. 

Inflammation  of  the  Cervix. — Catarrh  of  the  cervix  is  caused  by 
gonorrhea  and  by  infection  from  unclean  instruments.  It  may  be 
secondary  also  to  laceration  and  eversion  of  the  cervix,  to  the  use  of 
cold  douches,  to  imperfect  involution  of  the  cervix  after  labor,  mis- 
carriage or  abortion,  or  to  malposition  of  the  uterus.  The  only  symp- 
tom referable  directly  to  the  catarrh  itself  is  a  thick,  tenacious  discharge 
which  is  mucous  or  mucopurulent  and  may  prevent  conception.  Other 
symptoms  depend  upon  complicating  or  causative  lesions,  and  are: 
sensation  of  a  dull,  heavy  weight  and  dragging  in  the  pelvis,  burning 
in  the  vagina,  backache,  vertical  headache,  menorrhagia,  etc. 

Examination. — Inspection  shows  the  cervix  slightly  enlarged  and  con- 
gested. The  external  os  is  open  and  filled  with  a  thick,  tenacious  secre- 
tion. Upon  wiping  this  away  the  mucosa  of  the  cervical  canal  is  seen 
to  be  prolapsed  slightly  beyond  the  external  os,  giving  an  appearance 
resembling  but  at  once  distinguishable  from  eversion.  Surrounding  the 
prolapsed  mucosa  there  may  be  an  area  of  true  superficial  erosion  of 
the  mucosa  of  the  vaginal  cervix.  Nabothian  cysts  may  be  present, 
also  some  increase  of  the  connective  tissue  and  hypertrophy. 

Newgrowths. — Cervical  Polyp. — ^A  cervical  polyp  is  produced  by 
an  outgrowth  from  the  cervical  mucous  membrane  which  finally 
becomes  pedunculated.  Polyps  vary  in  shape  and  in  size;  they  may 
be  elongated  or  pyriform,  depending  upon  whether  they  lie  within  the 
cervical  canal  or  project  from  the  external  os;  they  vary  in  size  from  a 
pea  to  a  walnut. 

The  syinptoms  are  leucorrhea,  from  an  overproduction  of  cervical 
mucus,  menorrhagia,  and  dysmenorrhea.  Metrorrhagia  may  occur 
after  sexual  intercourse  or  some  unusual  trauma.  Inspection  shows  a 
pedunculated,  spongy,  or  velvety  tumor  lying  in  or  projecting  from  the 
cervical  canal.  The  external  os  is  patulous;  the  tumor  is  usually  bright 
red  in  color,  and  in  external  cases  its  pedicle  can  be  detected  passing 
into  the  cervical  canal.  Adenomatous  polyps  are  to  be  distinguished 
from  small  pedunculated  fibroid  tumors  of  the  cervix. 

Pedunculated  fibroid  tumors  of  the  cervix  feel  smooth  and  hard;  they 
are  usually  of  considerably  greater  size  than  polyps  and  have  a  pinkish 
white  color,  unless  necrotic  changes  have  occurred,  when  they  appear 
gangrenous  and  there  is  a  fetid  discharge.  Pedunculated  fibromyomata 
of  the  cervix  also  cause  greater  menorrhagia  and  more  often  metrorrhagia 
than  do  polyps. 

Venereal  Warts  of  the  Cervix. — Papillary,  or  warty,  outgrowths  of  the 
cervical  mucosa  are  rare.  They  are  not  as  indurated  and  do  not  bleed 
as  readily  on  palpation  as  carcinoma.  In  all  cases,  however,  as  the 
condition  is  suggestive  of  malignancy,  the  entire  growth  should  be 
excised  at  once  and  the  diagnosis  made  microscopically. 

Cancer  of  the  Cervix. — Cancer  of  the  cervix  occurs  usually  between  the 
ages  of  thirty  and  fifty  years;  most  frequently  at  about  the  time  of  the 
menopause.     It  may  occur  in  early  adult  life.      Almost  invariably  it 


718 


GYNECOLOGICAL  DIAGNOSIS 


affects  the  childbearing  woman  and  especially  those  who  have  had 
repeated  pregnancies.  A  badly  lacerated  cervix  predisposes  to  cancer. 
The  disease  begins  either  upon  the  vaginal  aspect  of  the  cervix  or  within 
the  cervical  canal. 

Symptoms. — There  are  no  symptoms  pathognomonic  of  cancer.  The 
earliest  symptom  is  usually  hemorrhage  between  the  regular  menstrual 
periods — bleeding  from  the  uterus  after  exertion,  sexual  intercourse,  or 
straining  at  stool.  Hemorrhage  from  a  cancer  which  develops  after 
the  menopause  has  often  been  taken  for  a  return  of  the  menstrual 
flow.  The  first  symptoms  may  be  an  inoffensive  leucorrheal  dis- 
charge. Late  in  the  disease,  when  the  carcinoma  begins  to  undergo 
disintegration  and  is  spreading  widely,  there  are  frequent  and  ex- 
hausting hemorrhages,  profuse  fetid  discharge,  pain,  and  cachexia. 
The  discharge  at  this  time  is  purulent,  bloody,  and  mixed  with  pieces 
and  shreds  of  putrefying  cancerous  tissue.  The  pain  is  either  dull 
and  gnawing  or  sharp  and  lancinating.  It  is  referred  to  the  sacrum, 
crest  of  the  ilium,  ovarian  region,  or  along  the  sciatic  nerve.  If  the 
cervical  canal  is  blocked  and  the  uterus  becomes  distended  with  blood, 

pus,  or  gas  (hemato-, 
Fig.  440  pyo->  OT  physomctra), 

the  patient  may  com- 
plain of  colicky  pain 
or  intense  bearing- 
down  sensations.  The 
anemia  and  the 
cachexia  of  cancer  are 
due  to  the  loss  of 
blood  and  the  absorp- 
tion of  toxins  from 
necrotic  cancerous 
tissue. 

Examination.  — Un- 
less the  diagnosis  is 
made  early,  the  case  is 
hopeless.  Carcinoma 
beginning  upon  the 
vaginal  aspect  of  the 
cervix  is  easier  to  diag- 
nosticate early  than  carcinoma  which  originates  in  the  cervical  canal. 
In  the  early  stage  of  either  form  the  cervix  feels  thickened  and  hard, 
and  hemorrhage  is  apt  to  follow  palpation.  Upon  exposure  of  the  cervix 
in  the  external  form,  numerous  large  and  small  bosses  are  seen  on  the 
mucosa  which  have  a  glazed,  bluish  white  appearance,  as  though  the 
tissue  were  very  tense  and  ready  to  burst.  On  careful  study  at  several 
points  masses  of  teat-like  or  branching  papillse  are  seen  which  are 
very  friable  and  bleed  readily.  Often  the  papillae  are  held  together 
in  masses  by  ropy  mucus,  and  may  be  easily  overlooked  (Cullen). 
Later  they  grow  rapidly  and  form  cauliflower-like  projections. 


^ 

Bi 

^ 

m    ^ 

3 

B 

fk 

a|i 

H^ 

V 

^W/ 

%L 

_ J 

^H^^ 

Isf^.;:^ 

Wf 

"•Hs 

ipp*** 

Early  carcinoma  of  the  anterior  cervical  lip. 


THE  CERVIX 


719 


Carcinoma  may  appear  early  also  as  an  ulceration.  True  ulceration 
of  the  cervix,  that  is,  actual  loss  of  tissue,  except  it  be  very  superficial, 
is  almost  always  cancerous.  The  cancerous  ulcer  bleeds  readily,  is 
indurated,  and  has  friable  edges.  When  carcinoma  begins  in  the 
cervical  canal  low  down,  the  os  is  dilated  and  the  growth  may  be  seen 
through  the  cervical  canal.  When  it  starts  high  up  in  the  canal,  the 
growth  may  be  far  advanced  before  it  becomes  visible.  The  only 
evidence  in  these  cases  is  from  the  hard  nodular  state  of  the  cervix 
and  the  tendency  to  hemorrhage  after  palpation.  In  advanced  cases 
there  are  cauliflower  masses  projecting  from  the  cervix  or  a  deep  ulcer 
of  the  cervix.  In  the  final  stage  of  any  form  of  cancer,  the  cervix  is 
destroyed  and  the  cancerous  excavation  extends  to  the  surrounding 
tissues  and  organs. 

As  already  stated,  a  diagnosis  of  carcinoma  of  the  cervix,  except  in 
the  early  stages,  is  useless,  so  far  as  a  cure  of  the  disease  is  concerned. 


Fig,  441 


Same  case  as  Fig.  440,  a  part  of  the  cancerous  area  magnified,  showing  the  finger-like  projections. 


Early  carcinoma  of  the  cervix  must  be  distinguished  from  an  eversion 
of  the  cervical  lips,  prolapse  of  the  cervical  mucosa  and  cervical  catarrh, 
cystic  degeneration  of  the  cervix,  venereal  warts,  chancre,  tuberculosis, 
small  interstitial  myomata,  sloughing  submucous  myomata,  and  cervical 
polyps.  In  any  suspicious  case,  when  the  diagnosis  is  not  certain, 
curettage  of  the  uterus  and  amputation  of  the  cervix,  or  trachelor- 
rhaphy should  be  performed  at  once  and  the  excised  tissue  and  the 
curettings  should  be  submitted  to  expert  microscopic  examination. 

Sarcoma  of  the  Cervix. — Sarcoma  of  the  cervix  is  much  less  frequent 
than  carcinoma.  There  are  certain  cases  of  sarcoma  (grape-like)  in 
which  the  tumor  consists  of  outgrowths  which  appear  cystic  and 
resemble  the  hydatidiform  mole.    These  growths  usually  occur  in  persons 


720  GYNECOLOGICAL  DIAGNOSIS 

under  the  age  of  twenty  and  are  rather  characteristic  in  appearance. 
Other  varieties  of  sarcoma  of  the  cervix  are  difiicuh  to  differentiate 
from  cancer  except  by  a  microscopic  examination. 

THE  UTERUS. 

Malformations. — Infantile  uterus  varies  from  a  uterus  smaller  than 
normal  to  one  represented  simply  by  a  fibrous  cord. 

Double  Uterus. — Two  complete  uteri  lying  side  by  side- — each  has  one 
round  ligament,  one  tube,  and  one  ovary. 

Bicornate  Uterus.— The  union  of  the  Miillerian  ducts  has  occurred 
at  a  lower  point  than  normal,  giving  the  uterus  a  "Y"  shape. 

Uterus  Septus. — ^The  uterus  has  a  normal  appearance  externally,  but 
the  endometrial  cavity  is  divided  into  two  by  a  median  septum;  each 
of  these  cavities  communicates  with  the  tube  on  its  corresponding  side. 

In  either  the  bicornate  or  the  septate  uterus  pregnancy  may  occur 
.  on  one  side;  or  one  horn  or  one  division  may  be  imperforate,  resulting 
in  hematometra. 

Uterine  Displacements.- — Retroposition  of  the  uterus  is  usually 
caused  by  childbirth,  being  preceded  or  accompanied  by  relaxation  of 
the  pelvic  floor,  abdominal  wall,  and  the  uterine  ligaments,  and  by 
subinvolution  of  the  uterus.  Constant  coughing  or  straining  (hard 
work)  predispose  to  retroposition.  Pelvic  inflammatory  disease  may 
complicate  retroposition  of  the  uterus.  In  such  a  case  the  uterus  is 
bound  down  by  adhesions.  Falls,  violent  contortion  of  the  body,  or  a 
sudden  effort  to  lift,  may  cause  retroposition  in  the  young.  Retroposition 
may  also  be  congenital.  It  always  precedes,  to  a  certain  degree, 
descensus  or  prolapse. 

Retroflexion  is  a  bending  of  the  fundus  backward  on  the  cervix,  and 
is  commonly  associated  with  retroposition.  The  symptoms  include 
vertical  or  occipital  headache,  sacral  backache,  and  a  feeling  of  weight 
and  dragging  in  the  pelvis  which  extends  into  the  thighs.  Irritability 
of  the  bladder  and  constipation  frequently  arise.  The  symptoms  are 
relieved  by  the  recumbent  posture.  Dysmenorrhea,  menorrhagia,  and 
leucorrhea  may  be  present  if  there  are  congestion  and  chronic  inflam- 
mation of  the  endometrium. 

Diagnosis. — The  body  of  the  uterus  is  not  felt  in  its  normal  anteposi- 
tion;  the  cervix  is  not  directed  toward  the  coccyx,  as  in  the  normal 
position,  but  lies  in  the  axis  of  the  vagina.  The  body  of  the  uterus  is 
felt  through  the  posterior  vaginal  fornix;  it  is  directed  backward  toward 
the  sacrum.  There  is  an  angle  of  retroflexion  between  the  cervix  and 
the  body.  By  sinking  the  abdominal  hand  deeply  into  the  pelvis,  below 
the  promontory  of  the  sacrum,  the  fundus  can  be  palpated  between  the 
two  hands. 

Descensus  and  Prolapsus  Uteri. — Descensus  is  the  first  stage  of  prolapsus; 
when  the  uterus  falls  slightly  below  its  normal  level  it  is  said  to  be  in 
descensus.  Retroversion  is  nearly  always  present  before  descensus  or 
prolapsus   occurs.      There  are  various  degrees  of  prolapsus  best  de- 


THE   UTERUS  721 

scribed  by  the  position  of  the  cervix:  (1)  What  may  be  called  descensus, 
when  the  cervix  has  descended  into  the  vagina  to  an  appreciable  degree; 
(2)  when  the  cervix  presents  at  the  vulvar  outlet;  (3)  when  the  entire 
uterus  is  outside  the  body,  spoken  of  also  as  procidentia. 

Exceptionally  prolapse  takes  place  as  the  result  of  a  violent  muscular 
effort.  Usually  it  is  the  final  result  of  relaxation  of  the  pelvic  floor, 
abdominal  walls,  and  uterine  ligaments.  As  the  organ  descends  into  the 
vagina,  the  latter  is  inverted;  the  bladder  wall  and  the  rectal  wall  may 
or  may  not  come  down  with  the  vagina.  In  case  the  prolapse  is  mainly 
caused  by  traction  on  the  cervix  from  a  relaxed  pelvic  floor,  and  the 
fundus  of  the  uterus  is  held  in  fair  position  by  its  ligaments  and  the 
retentive  power  of  the  abdomen,  there  occurs  an  elongation  and  a  thin- 
ning of  the  supravaginal  cervix.  The  symptoms  are  those  of  a  relaxed 
pelvic  floor,  depending  in  severity  upon  the  degree  of  the  prolapsus. 
Bladder  and  rectal  symptoms  as  described  under  cystocele  and  rectocele 
are  present.  In  complete  prolapsus  there  may  be  considerable  interfer- 
ence with  walking;  pressure  ulcers  of  the  vaginal  mucosa  may  develop, 
accompanied  by  a  foul-smelling  discharge.  The  symptoms  vary  in 
intensity  in  different  individuals,  and  sometimes  bear  no  relation  to  the 
extent  of  the  displacement. 

Examination. — Procidentia  is  readily  recognized.  The  pear-shaped 
tumor  projecting  from  the  vulva  with  the  cervical  canal  at  its  apex  can 
hardly  be  mistaken  for  anything  else.  Inversion  of  the  uterus  and  a 
pedunculated  fibroid  may  bear  some  resemblance.  Any  doubt  is  dis- 
pelled by  putting  the  patient  in  the  knee-chest  position,  when  in  the  case 
of  prolapsus  the  tumor  is  readily  reduced.  In  minor  degrees  the  uterus 
may  go  back  more  or  less  completely  when  the  woman  is  in  the  dorsal 
position,  even  though  it  projects  from- the  vagina  when  she  is  erect.  The 
degree  of  descensus  can  be  determined  by  having  the  patient  "bear 
down"  or  by  pulling  on  the  cervix  with  a  tenaculum.  When  there  is 
supravaginal  elongation  of  the  cervix  the  fundus  is  not  correspondingly 
prolapsed  and  the  endometrial  cavity  is  lengthened. 

Inflammations. — Acute  endometritis  is  due  to  gonorrhea  or  to  septic 
infection.  The  symptoms  in  the  gonorrheal  form  begin  during  or  after 
a  menstrual  period;  if  during  a  period,  the  flow  suddenly  stops;  if  after 
a  period,  there  is  a  diminution  in  the  cervical  leucorrhea,  the  attack 
is  marked  by  pain  in  the  back  and  lower  abdomen,  vesical  irritability, 
and  tenesmus,  constipation,  headache,  rise  of  temperature  (101°)  and 
pulse.     Within  a  few  days  a  profuse  purulent  discharge  appears. 

Examination  of  the  excretion  from  the  vulvovaginal  glands  or  from 
Skene's  tubules  will  often  reveal  the  gonococcus.  Gonorrheal  endo- 
metritis readily  passes  into  gonorrheal  salpingitis,  and  it  is  usually  hard 
to  say  where  one  ends  and  the  other  begins. 

In  the  septic  form  the  symptoms  follow  the  introduction  of  septic 
material  into  the  endometrial  cavity,  either  by  an  instrument  or  by  the 
finger.  The  uterus  may  be  puerperal  or  not.  If  puerperal  the  condition 
is  a  form  of  puerperal  sepsis  and  more  serious  than  when  the  uterus  has 
not  been  pregnant.  The  symptoms  in  general  resemble  those  of  acute 
46 


722  GYNECOLOGICAL  DIAGNOSIS 

gonorrheal  endometritis,  but  are  more  severe;  the  temperature  and  the 
pulse  are  higher;  chills  or  chilly  sensations  are  more  frequent,  and  the 
evidences  of  a  toxemia  are  more  likely  to  appear.  The  local  symptoms 
depend  upon  whether  the  uterus  is  puerperal  and  upon  the  nature  of  the 
infecting  organism.  If  the  infection  is  of  a  virulent  type,  there  may  be 
little  local  reaction;  in  this  case  the  disease  rapidly  advances  beyond  the 
endometrium,  toxemia  or  bacteremia  develop,  and  the  patient  dies  with 
few  structural  changes  in  the  pelvis.  With  less  dangerous  infection  in  a 
puerperal  case  there  is  at  first  a  diminution,  and  later  an  increase  in  the 
lochial  discharge.  In  case  placental  or  decidual  tissue  has  been  retained 
within  the  uterus,  the  lochia  has  a  foul  odor.  In  non-puerperal  cases, 
there  is  a  puriform  discharge  streaked  with  blood. 

Examination. — Bimanual  palpation  of  the  uterus  reveals  enlargement, 
tenderness,  and  perhaps  edema.  The  os  is  usually  patulous.  It  is 
difficult  to  differentiate  acute  endometritis  from  acute  metritis  or  mild 
inflammatory  lesions  of  the  appendages. 

Chronic  endometritis  usually  occurs  in  association  with  some  other 
pelvic  lesion,  such  as  retroposition  of  the  uterus,  fibroid  tumor,  or 
inflammatory  disease  of  the  appendages.  It  may  exist  alone.  Leucor- 
rhea  is  the  most  common  symptom.  The  discharge  is  thin  unless  the 
cervix  is  coincidently  the  seat  of  catarrh;  dysmenorrhea,  profuse  men- 
struation, and  in  exceptional  cases  metrorrhagia  may  be  caused  by 
chronic  endometritis.    As  an  independent  lesion  it  has  little  significance. 

Acute  metritis  is  customarily  associated  with  endometritis  of  the  septic 
type  and  other  inflammatory  pelvic  lesions.  Its  symptoms  vary  between 
those  of  septic  endometritis  and  pelvic  peritonitis,  from  which  it  is 
difficult  and  unimportant  to  differentiate. 

Chronic  metritis  is  the  residuum  of  an  acute  infection  or  the  result  of 
long-continued  subinvolution  of  the  uterus.  It  is  frequently  associated 
with  chronic  endometritis  and  displacement.  The  symptoms  are  back- 
ache and  dragging  sensations  in  the  lower  abdomen,  profuse  menstrua- 
tion, and  an  irritating  leucorrhea.  The  uterus  is  symmetrically  enlarged. 
The  diagnosis  is  made  by  excluding  fibroid  tumor  and  cancer. 

Newgrowths. — Cancer  of  the  body  of  the  uterus  occurs  somewhat 
later  in  life  than  cancer  of  the  cervix;  usually  between  the  ages  of  fifty 
and  sixty.  It  is  often  found  in  single  or  nulliparous  women.  Fibroid 
tumor  seems  to  predispose  to  carcinoma. 

Symptoms. — ^The  earliest  symptom  usually  is  metrorrhagia.  Menor- 
rhagia may  be  the  first  indication  of  the  disease.  Sometimes  more  or 
less  periodical  hemorrhage  occurs  after  the  menopause  and  is  taken  by 
the  patient  for  a  return  of  menstruation.  Metrorrhagia  may  follow 
coitus,  straining  at  stool,  or  any  pronounced  exertion.  The  onset  of 
leucorrhea  or  the  exaggeration  of  a  chronic  discharge  may  be  the  first 
symptom.  The  discharge  is  commonly  serous;  it  may  have  a  disagree- 
able odor  and  cause  irritation  of  the  external  genitalia;  it  may  be  streaked 
with  blood.  There  is  little  or  no  pain  in  the  earlier  stages.  After  the 
disease  is  advanced,  hemorrhage  increases  in  amount  and  is  more  or 
less  constant.     There  is  a  profuse,  purulent,  dirty  brown  discharge. 


THE   UTERUS 


723 


which  has  a  putrid  odor,  and  contains  disintegrated  blood  clots  and 
shreds  of  necrotic  cancer  tissue.  Pain  is  constant  or  intermittent,  being 
described  as  shooting,  burning,  or  colicky.  It  is  felt  in  the  lower  abdo- 
men, lumbosacral  region,  thighs,  and  along  the  crest  of  the  ilium. 

Examination  in  the  Early  Stage. — ^The  uterus  is  normal  in  size  or 
slightly  and  symmetrically  enlarged.  It  may  be  a  little  softer  than  nor- 
mal; the  cervical  canal  is  patulous,  or  easily  dilatable.  Hemorrhage 
may  follow  bimanual  palpation.  Such  symptoms  in  a  woman  between 
forty-five  and  sixty  years  should  be  considered  indicative  of  malignant 
disease  until  proved  otherwise.  In  the  late  stages  the  uterus  is  enlarged, 
sometimes  irregularly.  The  finger  may  be  pushed  through  the  external 
OS  with  ease  and  friable,  necrotic  material  felt  within  the  endometrial 
cavity.  Early,  the  condition  must  be  diagnosticated  from  chronic  endo- 
metritis, mucous  polyp,  small  submucous  fibroid,  and  beginning  sar- 
coma.     Later,  from    sloughing   submucous  fibroid  and  retained   and 


Fig.  442 


Early  cancer  of  the  body  of  the  uterus.  The  small  area  involved  shows  the  importance  of 
curettement  in  making  an  early  diagnosis.  It  also  emphasizes  the  fact  that  the  operator  should 
reach  every  part  of  the  endometrium  and  furnish  the  pathologist  with  all  of  the  tissue  removed. 


putrefying  placental  tissue  and  advanced  sarcoma.  In  any  case  where 
doubt  exists,  and  this  is  frequent  in  early  cases,  the  uterine  cavity  should 
be  curetted  and  the  scrapings  should  be  submitted  to  a  pathologist  for 
diagnosis.  It  is  important  to  curette  the  uterus  thoroughly  and  reach 
every  part  of  the  endometrium,  and  to  have  every  particle  of  the  scrapings 
examined  (Fig.  442).  The  curettings  should  be  mounted  and  cut  in 
celloidin  or  paraffin,  and  examined  in  the  usual  way.  This  can  be 
accomplished  within  thirty-six  hours.  If  malignant  trouble  is  fomid,  a 
second  operation  can  then  be  undertaken  immediately.  It  is  unwise  to 
depend  upon  frozen  sections  of  the  endometrium  in  making  a  histological 
diagnosis. 

Sarcoma  of  the  Uterus. — Primary  sarcoma  of  the  uterus  is  rare.  Sar- 
comatous degeneration  occiu's  in  about  1  per  cent,  of  fibroid  tumors, 
most  often  in  the  submucous  varietv^  There  is  almost  nothing  symp- 
tomatic to  distinguish  between  primary  sarcoma  of  the  uterine  body 


724  GYNECOLOGICAL  DIAGNOSIS 

and  carcinoma.  The  clinical  significance  of  each  is  the  same.  The 
microscope  only  can  decide  between  them  positively.  The  following 
facts  in  regard  to  a  fibroid  tumor  may  be  indicative  of  sarcomatous 
degeneration:  the  patient  is  advanced  in  years;  the  tumor  is  submucous 
in  position;  there  is  a  sudden  increase  in  the  size  of  the  tumor  and  a 
coincident  increase  of  hemorrhage  and  discharge. 

Fibroid  Tumor  of  the  Uterus. — ^Fibroid  tumor  is  the  commonest  neo- 
plasm of  the  uterus.  It  occurs  during  the  period  of  menstrual  activity, 
from  the  thirtieth  to  the  forty-fifth  year.  It  is  more  frequent  in  sterile 
or  single  women  and  in  the  colored  race.  Fibroid  tumors  may  affect 
any  part  of  the  uterus,  but  they  are  much  less  likely  to  occur  in  the  cervix. 
From  their  position  in  the  uterine  wall,  fibroid  nodules  are  spoken 
of  as  subperitoneal,  intramural,  or  submucous. 

Symptoms. — The  chief  symptom  is  hemorrhage.  This  is  manifested  at 
first  as  an  increase  in  the  amount  or  the  duration  of  the  menstrual  flow. 
As  a  rule,  the  symptom  grows  worse  gradually,  and  finally  bleeding  occurs 
between  the  periods.  In  some  cases  there  is  little  hemorrhage.  Hemor- 
rhage is  most  severe  in  the  submucous  variety.  In  such  a  case  the  blood 
may  be  retained  for  a  time  inside  the  uterus,  and  may  then  come  away  in 
clots  and  be  partly  decomposed.  Leucorrhea  may  be  present  and  is  at  first 
thin  and  watery;  later  the  amount  of  leucorrhea  is  obscured  by  the  more 
or  less  constant  hemorrhage.  In  necrotic  submucous  fibroids  the  discharge 
is  putrid.  Pain  depends  upon  the  position  and  the  size  of  the  tumor. 
Severe  dysmenorrhea  may  be  produced  even  by  small  tumors  situated 
in  the  wall  of  the  uterus.  A  submucous  tumor  may  cause  labor-like 
pains  from  uterine  contractions  made  in  an  effort  to  expel  it.  There  is 
also  pain  from  the  pressure  which  a  tumor  may  exert  upon  the  surrounding 
structures.  Sciatic  or  crural  neuralgia,  backache,  and  a  feeling  of 
weight  and  dragging  in  the  pelvis  are  not  at  all  unusual.  Frequent, 
painful,  and  difficult  micturition  or  incontinence  of  urine  may  occur. 
Constipation  is  frequently  observed.  There  are  very  often  circulatory 
symptoms  in  cases  of  fibroid  tumor.  They  result  from  impoverishment 
of  the  blood  and  from  obstruction  to  the  pelvic  circulation.  The  cardio- 
vascular symptoms  are  manifested  by  palpitation  of  the  heart,  shortness 
of  breath,  hemic  murmurs,  edema,  and  varicosities  of  the  lower  extremi- 
ties. The  anemia  in  fibroid  tumor  depends,  in  uncomplicated  cases, 
largely  upon  the  amount  of  blood  lost.  The  skin  is  yellowish  white,  and 
the  woman  does  not  have  a  cachectic  appearance.  On  the  contrary, 
many  patients  grow  fat. 

Diagnosis. — Abdominal  Examination. — A  fibroid  tumor  may  be  of 
sufficient  size  to  rise  above  the  pelvic  brim  and  produce  an  en- 
largement of  the  abdomen.  Such  an  abdominal  enlargement  must  be 
differentiated  from  pregnancy  and  from  an  ovarian  cyst.  On  inspec- 
tion the  distention  of  the  abdomen  produced  by  a  fibroid  is  apt  to  be 
found  asymmetrical ;  it  is  more  prominent  on  one  side  than  on  the  other, 
or  it  occurs  entirely  to  one  side  of  the  median  line.  The  surface  of  the 
abdominal  wall  above  the  tumor  drops  suddenly  to  its  normal  level.  On 
palpation  inspection  is  confirmed.     The  fibroid  tumor  is  hard  and  some- 


THE   UTERUS 


725 


what  resilient.  The  surface  of  the  growth  is  frequently  knobby  and 
small  tumors  on  the  surface  of  larger  ones  may  sometimes  be  felt.  If  it 
can  be  determined  by  palpation  that  these  smaller  tumors  are  peduncu- 
lated, the  diagnosis  is  all  but  positive.  Percussion  of  a  fibroid  tumor 
distending  the  abdomen  gives  dulness  over  the  prominence  of  the  tumor 
and  resonance  surrounding  it,  except  toward  the  pelvic  brim.  There  are 
no  auscultatory  indications  of  a  fibroid.  If  the  fibroid  is  intramural  and 
distends  the  uterus  symmetrically,  it  may  be  impossible  to  distinguish  it 
from  early  pregnancy.  In  such  cases  it  is  advisable  to  keep  the  patient 
under  observation  until  fetal  movements  and  fetal  heart  sounds  would 
have  become  manifest  if  the  woman  were  pregnant.  It  should  be  remem- 
bered also  that  pregnancy  and  fibroid  tumor  may  co-exist. 


Fig.  443 


Fibroid  tumor  of  the  uterus  distending  the  abdomen.  Note  the  slightly  irregular  outline  and 
the  abrupt  fall  of  the  surface  line  from  the  upper  pole  of  the  mass  to  the  epigastrium.  The 
abdominal  wall  is  pushed  out  by  the  hard,  unyielding  mass  within. 


Bimanual  Palpation. — Submucous  Tumors. — The  uterus  is  enlarged  and 
more  or  less  symmetrical.  It  is  harder  than  the  pregnant  uterus.  If  the 
tumor  is  pedunculated  it  sometimes  dilates  the  cervix  and  presents  itself 
in  the  cervical  canal,  or  it  may  be  extruded  from  the  canal  and  hang  by  its 
pedicle  in  the  vagina.  In  the  case  of  small  submucous  tumors  a  positive 
diagnosis  can  be  made  only  after  dilatation  of  the  cervix  and  intra-uterine 
exploration  by  means  of  the  finger,  sound,  or  curette.  Interstitial  tumors: 
The  cervix  fuses  directly  with  the  enlarged  fundus.  It  sometimes  projects 
from  the  surface  of  the  latter  like  a  nipple  from  the  breast.  The  uterus 
is  usually  somewhat  irregular  and  of  increased  density.  The  uterine 
body  cannot  be  outlined  distinctly  from  the  mass.  This  form  of  tumor 
is  most  difficult  to  distinguish  from  pregnancy.  Subperitoneal  tumors: 
The  uterus  is  studded  with  hard,  knob-like  protuberances.  If  they  are 
pedunculated,  the  diagnosis  is  clear.  When  the  growths  are  confined 
to  one  side  of  the  uterus  or  to  the  fundus  the  uterus  can  be  outlined  as  a 
distinct  but  attached  body.     When  the  tumor  is  single  and  pedunculated 


726  GYNECOLOGICAL  DIAGNOSIS 

an  ovarian  growth  must  be  excluded;  an  attempt  should  be  made  to 
isolate  the  ovary  upon  the  affected  side.  If  a  subperitoneal  fibroid, 
which  rises  out  of  the  pelvis  and  distends  the  abdomen,  is  pushed  up- 
ward by  the  external  hand,  the  uterus  will  immediately  follow.  If  the 
tumor  is  held  in  that  position  and  the  uterus  is  drawn  downward,  the 
pedicle  of  the  tumor  may  be  felt  at  its  attachment  to  the  uterus  by  rectal 
palpation. 

Tuberculosis  of  the  uterus  is  usually  complicated  by  tuberculosis  of  the 
tubes  and  of  the  pelvic  peritoneum.  The  symptoms  of  the  uterine  trouble 
itself  may  resemble  those  of  carcinoma.  There  may  be  a  profuse  leu- 
corrheal  discharge  containing  cheesy  particles.  The  body  of  the  uterus 
may  be  considerably  hypertrophied.  A  positive  diagnosis  can  be  made 
only  by  the  microscopic  examination  of  curettings. 

Inversion  of  the  uterus  dates  from  labor  or  the  expulsion  of  a  submucous 
pedunculated  fibroid.  The  diagnosis  rests  upon  the  recognition  of  a 
pear-shaped  tumor  filling  the  vagina  and  covered  with  endometrium;  the 
tubal  ostia  may  be  distinguishable.  The  cervix  surrounds  the  pedicle  of 
the  tumor  and  the  endometrial  cavity  is  turned  inside  out.  There  is  a 
cup-shaped  depression  at  the  fundus. 

Chorio-epithelioma  of  the  uterus  is  an  epithelial  newgrowth  arising  from 
the  chorion  epithelium.  Half  of  the  cases  are  preceded  by  hydatidiform 
mole.  The  symptoms  develop  after  abortion  or  labor  and  include  a  rapid 
enlargement  of  the  uterus,  hemorrhage,  and  a  foul-smelling  discharge. 
The  growth  rapidly  extends  locally,  and  metastases  to  the  lungs  and  to 
other  organs  may  occur  very  soon.  The  diagnosis  depends  chiefly  upon 
a  microscopic  examination  of  pieces  of  the  tumor  secured  by  curettement. 
It  is  important  to  recognize  the  lesion  without  delay. 

Hematometra  is  a  distention  of  the  uterus  with  blood.  It  is  usually 
associated  with  atresia  of  the  vagina  and  hematocolpos.  The  uterus 
may  be  distended  alone,  the  condition  then  resulting  from  an  atresia 
of  the  cervix.  Under  these  circumstances  the  uterus  is  frequently 
septate  or  bicornate,  and  the  atresia  and  the  hematometra  affect  one  side. 
There  are  periodic  colicky  pains  associated  with  menstrual  molimina 
and  a  globular  tumor  in  the  lower  abdomen. 

Pyometra  and  physometra  exist  when  the  uterus  is  distended  with  pus 
and  gas  respectively.  They  are  almost  invariably  associated  with 
carcinoma  or  sarcoma.  The  patient  is  septic  and  complains  of  colicky 
pains.     The  uterus  is  enlarged  and  sensitive. 


THE  TUBES  AND  THE  OVARIES. 

Malformations. — Hematosalpinx.- — The  tube  is  distended  with  blood; 
the  condition  may  exist  alone  or  in  connection  with  hematometra  or 
with  hematometra  and  hematocolpos,  as  a  consequence  of  some  form 
of  gynatresia. 

Elongation  and  twisting  of  the  tube  or  a  persistence  of  its  fetal  type 
favor  tubal  pregnancy  and  sterility. 


THE  TUBES  AND  THE  OVARIES  727 

Rudimentary  or  ill-developed  ovaries  have  imperfectly  formed  follicles 
or  none  at  all  and  are  an  occasional  cause  of  sterility. 

Inflammations. — Acute  salpingitis  usually  results  from  gonorrheal 
infection.  Gonorrhea  of  the  endometrium  frequently  extends  to  the 
tubes  and  from  these  in  turn  the  infection  progresses  toward  and  in- 
volves the  pelvic  peritoneum.  Acute  gonorrheal  salpingitis  is  usually 
associated  with  gonorrheal  pelvic  peritonitis.  Its  symptoms,  diagnosis, 
etc.,  are  found  under  that  subject  on  page  728. 

Pyosalpinx  is  a  distention  of  the  tube  with  pus.  It  results  from  a 
suppurative  inflammation  of  the  mucosa  with  a  coincident  closure  of  the 
abdominal  and  the  uterine  ostia.  The  symptoms  during  the  formative 
stage  of  the  lesion  are  those  of  acute  gonorrheal  pelvic  peritonitis  (see 
p.  728).  After  full  development  and  the  subsidence  of  active  inflam- 
matory processes,  the  symptoms,  examination,  etc.,  are  those  described 
under  chronic  pelvic  peritonitis  (see  p.  729). 

Abscess  of  the  ovary  usually  results  from  puerperal  infection  which 
reaches  the  ovary  by  way  of  the  lymph  channels.  It  may  also  be  pro- 
duced by  the  extension  of  infection  from  an  acute  gonorrheal  salpingitis 
to  a  Graafian  follicle  or  a  corpus  luteum,  or  it  may  be  formed  by  the 
bursting  of  a  pyosalpinx  into  an  adherent  Graafian  follicle  or  a  cystic 
corpus  luteum.  The  symptoms  during  the  formative  stage  are  those 
described  under  puerperal  pelvic  peritonitis,  with  which  it  is  commonly 
associated  (see  p.  728).  They  are  less  apt  to  subside  spontaneously 
than  in  gonorrheal  salpingitis.  If  the  inflammatory  process  becomes 
quiescent  the  symptoms  resemble  those  of  chronic  pelvic  inflammatory 
disease. 

Pelvic  Inflammatory  Disease. — Inflammatory  affections  of  the  tubes, 
the  ovaries,  and  the  pelvic  peritoneum  are  so  closely  related  and  so  fre- 
quently combined  that  they  may  be  considered  together.  It  is  very 
often  impossible  to  say,  in  a  given  case,  which  of  the  three  is  principally 
involved.  A  comparison  of  the  conditions  found  at  operation  with  the 
cause  of  the  inflammation  has  shown  that  certain  forms  of  infection  affect 
particularly  certain  organs.  Thus,  it  is  known  that  gonorrhea  frequently 
produces  pyosalpinx  in  pelvic  inflammatory  disease,  and  that  sepsis 
following  labor  or  instrumentation  of  the  uterus  does  not,  as  a  rule,  pro- 
duce pyosalpinx.  It  is  shown  further  that  the  last-mentioned  form  of 
infection  is  more  apt  to  result  in  an  ovarian  abscess  or  in  an  inflammation 
of  the  cellular  tissue  of  the  broad  ligaments.  The  pelvic  peritoneum  is 
usually  involved  in  all  forms  of  pelvic  inflammation.  With  this  explana- 
tion the  various  inflammatory  affections  of  the  tubes,  the  ovaries,  and  the 
pelvic  peritoneum  will  be  considered  under  the  term  pelvic  peritonitis. 

Acute  Pelvic  Peritonitis. — Acute  pelvic  peritonitis  may  result  from 
gonorrhea,  from  septic  infection  following  abortion  or  labor,  and  from 
infection  incident  either  to  an  operation  upon  the  uterovaginal  canal  or 
to  some  instrumentation  of  the  uterus. 

Gonorrheal  Pelvic  Peritonitis. — The  symptoms  usually  begin  during  or 
immediately  after  a  menstrual  period.  The  patient  gives  the  history  of 
a  leucorrheal  discharge  which  originated  after  marriage  or  after  suspi- 


728  GYNECOLOGICAL  DIAGNOSIS 

cious  intercourse.  There  are  severe  sharp  pains  in  the  lower  abdomen, 
usually  worse  on  one  side.  The  menstrual  flow  may  be  arrested.  Urina- 
tion is  frequent  and  painful,  the  bowels  are  constipated;  the  abdomen  is 
distended,  and  the  abdominal  muscles  are  tense  or  rigid.  Nausea  and 
vomiting  may  occur.  The  temperature  varies  between  101°  and  103°; 
the  pulse  is  increased  proportionately;  110  to  120  beats  per  minute  is  not 
uncommon. 

Examination. — If  no  history  confirmatory  of  gonorrheal  infection  can 
be  elicited,  Skene's  glands,  the  vulvovaginal  glands,  and  the  cervix 
should  be  inspected  for  evidence  of  the  disease,  and  if  it  is  expedient 
smears  should  be  made  and  examined  for  the  gonococcus.  Bimanual 
pelvic  examination  is  unsatisfactory  at  first  because  of  tenderness  and 
rigidity.  Usually  it  is  possible  to  determine  that  the  uterus  is  more  or 
less  fixed,  and  that  any  attempt  to  move  it  causes  intense  pain.  After 
several  days,  under  appropriate  treatment,  the  pyrexia,  the  rapid  pulse, 
and  the  abdominal  tenderness  and  rigidity  subside.  Then,  upon  bi- 
manual palpation  the  uterus  is  found  to  be  fixed,  and  back  of  it,  on  one 
or  on  both  sides,  induration  is  felt  through  the  vault  of  the  vagina.  The 
pelvis  contains  inflammatory  masses  (pyosalpinx,  tuboovarian  abscess, 
encapsulated  intraperitoneal  abscess,  pelvic  exudate)  which  are  immova- 
ble and  very  tender,  and  have  a  more  or  less  globular  or  retort  shape. 
From  experience  it  is  known  that  in  the  majority  of  cases  of  gonorrheal 
pelvic  peritonitis  a  pyosalpinx  is  formed.  The  mass  felt  upon  palpation, 
however,  often  consists  of  the  tube,  the  ovary,  and  a  peritoneal  exudate 
bound  together,  and  it  is  often  impossible  to  determine  to  what  extent 
each  of  these  is  involved. 

Differential  Diagnosis  between  Gonorrheal  Pelvic  Peritonitis  and  Appen- 
dicitis.— In  appendicitis  there  is  often  the  history  of  a  previous  attack 
associated  with  an  indiscretion  in  diet,  or  habitual  overeating  and  chronic 
intestinal  indigestion.  Pain  at  first  is  not  well  localized,  affecting  more 
or  less  the  entire  upper  abdomen.  Later  it  is  localized  to  the  region  of  the 
appendix.  The  gastro-intestinal  symptoms,  nausea,  vomiting,  and 
constipation  are  more  pronounced  and  less  apt  to  respond  quickly  to 
treatment.  Pain  and  tenderness  are  at  a  higher  point  and  are  more  or 
less  confined  to  the  right  side.  There  is  no  fixation  of  the  uterus,  and 
simple  digital  pelvic  examination  is  not  painful. 

Puerperal  pelvic  peritonitis  dates  from  labor,  abortion,  or  some  intra- 
uterine operation  or  manipulation  during  pregnancy.  It  begins  suddenly 
with  a  chill  and  hyperpyrexia  (103°  to  105°),  or  gradually,  during  the  first 
few  days  of  the  puerperium.  The  pulse  is  usually  increased  out  of  pro- 
portion to  the  temperature.  There  may  be  no  actual  chills,  but  merely 
chilly  sensations.  There  is  pain  in  the  lower  abdomen,  worse  perhaps 
on  one  side;  there  is  abdominal  distention  and  more  or  less  tenderness 
in  the  hypogastrium.  Constipation  is  the  rule  early;  later,  in  some  of  the 
most  septic  cases  there  is  diarrhea.  Nausea  and  vomiting  are  common. 
The  lochia  is  usually  diminished  in  amount.  If  necrotic  material 
(placenta)  exists  inside  the  uterus  the  lochia  will  be  putrid.  In  some  of 
the  worst  cases  the  lochia  does  not  have  a  foul  odor. 


THE  TUBES  AND  THE  OVARIES  729 

Examination. — t'alpation  shows  the  uterus  enlarged  and  the  os  patu- 
lous. Beyond  this  at  first  there  is  little  information  to  be  gained.  Later 
the  uterus  is  fixed  and  pelvic  masses  are  found  on  one  or  both  sides. 
They  are  more  apt  to  be  unilateral  than  in  gonorrheal  pelvic  peritonitis. 
The  vaginal  vault  and  the  pelvic  masses  have  an  almost  stony  hardness; 
later,  if  suppuration  occurs,  the  masses  soften.  It  is  difficult  often  to 
differentiate  an  ovarian  from  a  tubal  enlargement,  as  there  is  a  pelvic 
exudate  which  surrounds  and  envelops  both  the  tube  and  the  ovary. 
Ovarian  abscess  is  more  common  than  pyosalpinx  in  puerperal  pelvic 
peritonitis. 

,  Instrumental  or  postoperative  pelvic  peritonitis  follows  operation  upon 
the  uterovaginal  canal  or  instrumentation  of  the  uterus.  It  may  be  a 
result  of  the  extension  of  a  gonococcus  infection  from  the  uterus  to  the 
tubes  and  the  pelvic  peritoneum.  It  may  be  produced  by  the  direct 
introduction  of  infectious  material  (attempts  to  produce  abortion)  into 
the  uterus.  When  due  to  the  spread  of  gonorrhea,  the  symptoms  are 
those,  already  discussed,  of  gonococcus  pelvic  peritonitis;  when  it 
follows  the  introduction  of  an  unclean  instrument  into  the  uterus  during 
pregnancy,  the  symptoms  are  those  described  under  puerperal  pelvic 
peritonitis  (p.  728).  If  pregnancy  actually  did  not  exist  and  yet  the 
uterus  is  infected,  the  symptoms  will  be  less  severe  than  in  the  puerperal 
form. 

Chronic  Salpingitis. — See  Chronic  Pelvic  Peritonitis. 

Adherent  Tube  and  Ovary. — See  Chronic  Pelvic  Peritonitis. 

Hydrosalpinx. — See  Chronic  Pelvic  Peritonitis. 

Chronic  pelvic  peritonitis  is  the  residuum  of  a  previous  acute  peritonitis. 
Gonorrhea  is  more  apt  to  produce  it  than  puerperal  infection.  The  latter, 
as  a  rule,  either  results  in  death  or  is  entirely  relieved  by  symptomatic  or 
operative  treatment.  The  former  is  not  directly  dangerous  to  life,  but 
shows  no  tendency  to  spontaneous  cure,  and,  unless  the  diseased  organs 
are  removed  after  the  acuteness  of  the  attack  has  subsided,  they  may 
continue  to  give  trouble  and  be  responsible  for  recurrent  attacks  of 
acute  pelvic  peritonitis.  The  lesions  associated  with  chronic  pelvic 
peritonitis  comprise  chronic  pyosalpinx,  hydrosalpinx,  ovarian  abscess, 
cystic  enlargement  of  the  ovary,  tuboovarian  abscess  or  cyst,  intraperi- 
toneal collections  of  pus  or  serum,  and  adhesions  which  bind  the  pelvic 
organs  together  in  malposition.  When  the  pus  originally  present  has 
been  absorbed  and  serum  has  replaced  it  (hydrosalpinx,  tuboovarian 
cyst,  intraperitoneal  cyst),  the  recurrence  of  peritonitis  is  less  likely. 

Symptoms. — Backache,  pain  in  the  thighs  and  lower  abdomen,  pain 
during  defecation,  frequent  and  painful  urination,  irregularity  of  the 
menses,  menorrhagia,  dysmenorrhea,  and  persistent  leucorrhea.  In  the 
case  of  chronic  gonorrheal  pyosalpinx  there  are  repeated  attacks  of 
acute  pelvic  peritonitis. 

Examination  shows  fixation  of  the  uterus  with  or  without  displace- 
ment. Adnexal  masses  are  found  to  either  side  or  behind  the  uterus. 
It  is  difficult  to  positively  distinguish  the  tube  from  the  ovary  in  cases 
where  there  is  much  distortion  or  many  adhesions.     Tubal  enlargements 


730  GYNECOLOGICAL  DIAGNOSIS 

are  apt  to  be  sausage-shaped,  ovarian  enlargements  are  spherical  or 
elliptical,  tuboovarian  masses  are  retort-shaped. 

Tuberculosis  of  the  Tubes. — Tuberculosis  of  the  tubes  is  usually  sec- 
ondary to  tuberculosis  elsewhere,  although  it  is  more  frequent  than 
tuberculosis  of  any  other  part  of  the  genital  tract.  Both  tubes  are 
affected  as  a  rule,  but  the  lesion  may  be  farther  advanced  on  one  side. 
The  diseased  tube  may  have  the  form  of  an  ordinary  pyosalpinx,  its  true 
nature  being  recognized  only  by  microscopic  examination.  More  com- 
monly the  enlargement  is  nodular,  chalky  yellow  in  color,  and  confined 
to  distinct  areas,  the  intervening  parts  appearing  to  be  little  affected. 
Miliary  tubercles  may  be  present  on  the  serous  coat. 

Symptoms. — The  symptoms  are  not  often  distinctive,  and,  unless  there 
is  ascites  or  indications  of  tuberculosis  in  some  other  organ,  its  true 
nature  may  be  unsuspected.  In  young  virginal  women  tuberculosis  is 
the  most  frequent  cause  of  pelvic  inflammatory  disease.  The  symptoms 
in  general  resemble  those  of  chronic  pelvic  peritonitis  from  which  it  is 
often  indistinguishable  before  operation. 

Tubal  Pregnancy. — ^Tubal  pregnancy  may  affect  primipara,  but,  as  a 
rule,  multipara  in  whom  a  considerable  interval  has  elapsed  since  the 
birth  of  the  last  child. 

Symptoms. — Often  in  the  early  weeks  the  general  and  the  local  mani- 
festations are  quite  like  those  of  normal  pregnancy.  There  may  be  on 
the  contrary  very  little  or  no  evidence  of  pregnancy  whatever.  The 
menstrual  symptoms  are  extremely  variable.  In  the  majority  of  cases 
the  menstrual  flow  ceases  for  a  period  of  from  eight  to  twelve  weeks.  At 
that  time,  in  connection  with  the  death  of  the  fetus  or  a  rupture  of  the 
embryonic  sac,  there  is  a  discharge  of  decidual  tissue  and  blood  from  the 
uterus,  and  hemorrhage  continues  thereafter  either  at  irregular  intervals 
or  continuously.  After  the  second  month,  sometimes  earlier,  there  are 
periodic  pains  in  the  lower  abdomen  on  the  affected  side,  or  a  numbness 
or  an  aching  pain  in  the  groin.  The  pain  is  caused  by  contractions  of 
the  uterus  and  the  tube,  or  by  the  peritoneal  irritation  or  pressure  of 
the  enlarging  tube.  There  is  commonly  some  slight  degree  of  pyrexia — 
99°  to  100°.  The  bladder  is  frequently  irritable,  and  constipation  may 
be  marked. 

Rupture  of  the  tube  or  tubal  abortion  is  usually  preceded  by  par- 
oxysmal cramp-like  pains  of  great  severity  in  one  iliac  region.  At  the 
time  of  rupture  there  is  an  agonizing  stabbing  pain  on  the  diseased  side, 
followed  by  indications  of  internal  hemorrhage,  rapid,  running  pulse, 
air  hunger,  dilatation  of  the  pupils,  and  a  cold,  clammy  skin.  There 
may  be  no  further  complaint  of  severe  pain,  but  the  patient  is  pallid  and 
bears  an  anxious  expression.  The  severity  and  degree  of  the  symptoms 
vary  in  relation  to  the  amount  of  blood  which  has  been  lost  and  the 
strength  of  the  patient.  Tubal  abortion  may  produce  the  same  symp- 
toms as  rupture.  Usually  the  stabbing  pain  does  not  occur  and  the 
symptoms  of  internal  hemorrhage  are  less  marked. 

Examination  before  rupture  shows  an  enlargement  of  the  uterus  rather 
less  than  would  correspond  to  the  duration  of  pregnancy.     There  are 


THE  OVARY  731 

softening  of  the  cervix,  discoloration  of  the  vagina,  and  the  mammary 
changes  of  pregnancy;  all  may  be  less  marked  than  usual  or  they  may 
be  absent  entirely.  IBimanual  examination  reveals  a  tubal  enlargement 
to  one  side  of  the  uterus.  It  may  be  small  and  freely  movable  in  the 
early  weeks  and  if  no  adhesions  have  formed;  as  a  rule,  there  is  a 
slightly  adherent  mass  of  some  size,  and  the  uterus  is  correspondingly 
displaced. 

Immediately  after  rupture  has  occurred  the  remains  of  the  enlarged 
tube  may  be  found  by  bimanual  palpation  to  one  side  of  or  behind 
the  uterus.  Rupture  causes  a  diminution  in  the  size  of  the  tubal 
enlargement,  and  in  some  cases  almost  nothing  but  tenderness  and 
an  ill-defined  sense  of  fulness  will  be  distinguished  by  bimanual 
palpation.  When  the  hemorrhage  is  intraperitoneal  and  large,  the 
signs  of  free  fluid  in  the  peritoneal  cavity  may  be  elicited.  After 
tubal  abortion,  in  which  the  bleeding  is  slower  and  the  blood  coagulates, 
and  in  cases  examined  some  time  after  rupture,  bimanual  examination 
will  discover  a  pelvic  mass  which  usually  is  back  of  the  uterus,  displacing 
it  forward  and  upward  and  perhaps  to  one  side.  The  mass  is  doughy 
and  semisolid,  and  by  rectal  palpation  a  sensation  will  be  imparted  to 
the  finger  like  that  experienced  in  breaking  up  a  thick  jelly.  It  should 
be  emphasized  that  bimanual  palpation  must  be  very  gently  performed 
in  all  cases  of  suspected  tubal  pregnancy;  otherwise  it  may  cause  a  rup- 
ture or  abortion,  or,  if  either  has  already  occurred,  it  may  retard  the 
formation  of  a  clot  and  cause  renewed  hemorrhage. 


THE  OVARY. 

Prolapse  of  the  Ovary. — Caitses.— Prolapse  of  the  ovary  occurs  either 
alone  or  in  combination  with  retroposition  of  the  uterus.  In  the  former 
case  chronic  wasting  diseases  with  loss  of  the  pelvic  fat  and  relaxation 
of  the  ligaments,  increased  weight  of  the  organ  because  of  cystic  degen- 
eration, and  small  ovarian  tumors  are  causes.  Subinvolution  of  the 
infundibulo-pelvic  ligaments  may  produce  it.  The  left  ovary  is  more 
often  affected  than  the  right. 

Symptoms. — Pain  varying  from  a  dull,  heavy  ache  to  a  sharp,  agon- 
izing sensation,  with  faintness  and  nausea.  The  pain  is  relieved  by  a 
recumbent  posture.  It  is  made  worse  by  walking,  coitus,  and  defeca- 
tion. After  defecation  it  may  last  for  several  hours.  Dysmenorrhea 
and  menorrhagia  may  ensue.  Reflex  symptoms,  such  as  headache, 
indigestion,  nervousness,  and  mental  depression,  may  be  present. 

Examination. — Simple  digital  palpation  of  the  vaginal  vault  to  one 
side  of  the  cervix  discovers  the  ovary  lying  at  the  bottom  of  Douglas' 
cul-de-sac,  or  upon  bimanual  palpation  it  is  found  along  the  pelvic 
wall  at  a  slightly  higher  point.  Care  must  be  taken  to  distinguish  a 
prolapsed  ovary  from  a  fecal  mass  in  the  rectum  or  sigmoid. 

Cystic  degeneration  of  the  ovary  or  follicular  cysts  of  the  ovary  result 
from  an  inflammation  of  the  ovarian  surface  or  from  adhesions  between 


732  GYNECOLOGICAL  DIAGNOSIS 

the  ovary  and  the  pelvic  peritoneum  in  chronic  pelvic  peritonitis.  The 
fluid  of  maturing  Graafian  follicles  which  are  prevented  from  undergoing 
the  normal  rupture  is  retained  within  the  ovary.  Cystic  degeneration 
may  also  occur  in  a  prolapsed  ovary  as  the  result  of  slow  thickening 
of  the  ovarian  capsule,  due  to  the  more  or  less  constant  mechanical 
irritation  to  which  it  is  exposed;  rarely  there  may  be  thickening  of 
the  ovarian  capsule  and  cystic  degeneration  without  any  demonstrable 
cause. 

The  symptoms  and  the  objective  signs  are  dependent  upon  the 
associated  lesion,  being  usually  like  those  of  a  chronic  pelvic  peritonitis 
or  a  prolapsed  ovary.  In  the  rare  form  which  occurs  without  apparent 
reason  the  patient  suffers  from  backache,  pain  in  the  ovarian  region, 
severe  dysmenorrhea,  menorrhagia,  and  leucorrhea.  Nervous  symptoms 
are  often  pronounced.  On  palpation  the  ovaries  feel  larger  than  normal 
and  are  freely  movable  or  slightly  adherent. 

Ovarian  Tumors. — Glandular  cyst  is  the  most  common  ovarian 
tumor,  cystic  or  solid.  It  usually  develops  about  the  age  of  forty-two, 
although  it  may  occur  in  the  very  young  or  the  very  old.  Nullipara  and 
multipara  are  equally  susceptible. 

Symptoms. — There  may  be  no  indications  of  the  tumor  until  it  is 
large  enough  to  distend  the  abdomen.  Early  symptoms  are  dysmen- 
orrhea and  profuse  menstrual  flow.  As  the  ovarian  stroma  is  destroyed 
the  periods  become  scanty.  Pain  is  a  variable  symptom  and  usually 
depends  upon  torsion  of  the  pedicle  or  adhesions.  The  bowels  may 
be  constipated  and  the  bladder  irritable.  In  large  tumors,  distending 
the  abdomen,  digestive  disturbances  are  common;  anorexia,  nausea  and 
vomiting,  catarrhal  jaundice,  and  intestinal  obstruction  have  been 
noted.  The  heart  may  be  embarrassed  by  the  increase  of  intra- 
abdominal pressure  and  often  there  is  considerable  dyspnea.  The 
abdominal  wall  is  overstretched  and  very  thin  or  edematous;  dilated 
veins  appear  on  the  surface;  edema  of  the  vulva  and  of  the  lower 
extremities  may  be  present.  Hemorrhoids  and  ascites  are  not  infrequent 
complications.  With  increasing  impairment  of  nutrition  there  is 
progressive  emaciation,  and  the  face  has  a  weazened  appearance,  the 
fades  ovariana.    . 

Abdominal  Examination. — Ovarian  tumors  which  distend  the  abdo- 
men, must  be  differentiated  from  pregnancy,  uterine  fibroids,  ascites, 
and  an  excessive  accumulation  of  fat.  Inspection:  Large  tumors  distend 
the  abdomen  symmetrically,  the  greatest  prominence  being  in  the 
median  line  and  the  surface  smooth  and  regular.  The  abdominal 
wall  drops  gradually  from  the  umbilicus  to  the  ensiform.  Smaller 
tumors  may  lie  more  to  one  side  than  the  other,  but  a  median  position 
is  most  common  unless  the  cyst  is  adherent  or  intraligamentous. 
Palpation  confirms  inspection  in  regard  to  position.  The  tumor  is 
neither  so  hard  nor  so  distinctly  outlined  as  a  fibroid.  A  multilocular 
tumor  may  be  slightly  irregular,  but  it  has  no  knob-like  protuberances 
from  the  surface.  Fluctuation  may  be  elicited  in  large  tumors  and  in 
small  ones  which  are  unilocular  and  thin-walled.     In  large  cysts  the 


THE  OVARY 


733 


percussion  wave  may  be  limited  to  certain  areas  (loculi),  and  in  small 
multilocular  growths  with  thick  contents  there  may  be  little  trans- 
mission of  impulse.  The  'percussion  note  is  dull  over  the  tumor  and 
resonant  around  it  (coronal  resonance)  except  toward  the  pelvic  brim. 


Fig.  444 


Ovarian  cyst  distending  the  abdomen.     Note  the  regularity  of  outline,  the  general  sjmametry 
and  the  more  gradual  fall  of  the  abdominal  wall  from  the  umbilicus  to  the  epigastrium. 


Fig.  445 


Abdominal  enlargement  due  to  ascites.  The  peritoneal  cavity  is  filled  with  fluid.  The  surface 
line  of  the  abdomen  shows  a  less  abrupt  projection  than  in  the  case  of  a  fibroid  tumor  or  an 
ovarian  cyst.     The  distention  also  noticeably  affects  the  flanks. 


Bimanual  Palpation. — In  small  cysts  a  spherical  mass  is  felt  lateral  to 
and  behind  the  uterus,  which  is  commonly  displaced  anteriorly  and  to 
the  opposite  side.      The  smaller  the  tumor  the  more  it  is  found  to  one 


734  GYNECOLOGICAL  DIAGNOSIS 

side  and  the  less  the  uterus  is  displaced.  The  surface  is  quite  regular, 
and  fluctuation  can  usually  be  elicited  by  having  a  second  person  tap 
the  abdominal  fingers,  when  the  tumor  is  palpated  bimanually.  In  small 
multilocular  tumors  with  thick  contents  fluctuation  may  not  be  very 
distinct.  Unless  the  tumor  is  adherent  or  impacted  in  the  pelvis,  it  can 
be  displaced  above  the  brim  of  the  pelvis.  The  uterus  may  now  be 
distinctly  outlined  as  a  separate  body;  it  is  usually  normal  in  size. 
Moving  the  uterus  up  or  down  will  not  influence  the  position  of  the  tumor 
to  the  same  degree  as  is  noted  in  subperitoneal  pedunculated  fibroids. 
A  normal  ovary  cannot  be  felt  upon  the  affected  side. 

In  the  case  of  large  ovarian  cysts  which  fill  the  pelvis  and  distend  the 
entire  abdomen,  it  is  very  often  impossible  to  palpate  the  body  of  the 
uterus,  as  it  is  pressed  against  the  pelvic  wall  and  partially  enveloped 
by  the  lower  pole  of  the  tumor.  In  such  cases  a  sound,  passed  with 
aseptic  precautions  may  be  used  to  determine  the  size  and  position  of 
the  uterus. 

Papillomatous  ovarian  cyst  is  often  bilateral  and  does  not  usually 
reach  an  enormous  size.  There  is  little  distention  of  the  abdomen  except 
by  ascites,  with  which  it  is  frequently  complicated.  Papillomatous, 
warty,  or  cauliflower-like  masses  may  be  felt  through  the  vaginal  vault, 
or  perhaps  through  the  abdominal  wall,  if  the  patient  is  emaciated. 

Parovarian  Cyst.- — A  parovarian  cyst  is  usually  smaller  than  a  glandular 
cyst.  It  is  felt  low  in  the  pelvis  in  direct  relation  with  the  lateral  border 
of  the  uterus,  which  is  pushed  to  the  opposite  side.  There  may  be  some 
bulging  of  the  vaginal  vault  on  the  affected  side.  There  is  no  indura- 
tion. Fluctuation  is  usually  distinct.  In  the  case  of  a  very  large  par- 
ovarian cyst  distending  the  abdomen  the  surface  is  smooth  and  fluctua- 
tion is  very  distinct  over  the  entire  tumor. 

Dermoid  Cyst. — Dermoid  cysts  do  not  attain  the  size  of  glandular  cysts. 
They  may  develop  about  the  age  of  puberty.  The  physical  signs  are 
those  of  the  smaller  glandular  cysts,  but  they  are  prone  to  become 
adherent,  so  that  fixation  and  induration  of  the  surrounding  tissues  are 
not  uncommon.  Fluctuation  is  not  distinct,  but  the  tumors  have  a 
semisolid,  putty-like  consistency. 

Accidents  to  Ovarian  Cysts. — Acute  torsion  of  the  pedicle  of  an  ovarian 
cyst  is  marked  by  sudden  extreme  pain  in  the  lower  abdomen,  symptoms 
of  collapse,  and  slight  enlargement  of  the  tumor.  Rupture  of  an  ovarian 
cyst  is  evidenced  by  severe  pain,  the  general  symptoms  of  shock,  and  a 
complete  or  partial  disappearance  of  the  tumor.  The  severity  of  the 
symptoms  depends  upon  the  extent  of  the  rupture  and  the  amount  of 
hemorrhage.  Serous  contents  are  absorbed;  thick  mucilaginous  con- 
tents may  cause  low  grade  peritonitis  and  ascites;  if  the  cyst  is  papil- 
lomatous, the  warty  masses  will  become  transplanted  to  the  general 
peritoneum. 

Solid  Tumors  of  the  Ovary. — Fibroma,  sarcoma,  carcinoma,  and  papil- 
loma may  occur.  All  are  rare.  A  majority  of  the  solid  ovarian  tumors 
are  sarcomata.  The  symptoms  are  those  produced  by  pressure  and  by 
peritoneal  irritation.     They  are  most  apt  to  be  confused  with  single, 


THE  BLADDER  AND   URETHRA  735 

subperitoneal,  pedunculated,  fibroid  tumors  of  the  uterus.  A  body 
corresponding  to  the  position  and  size  of  the  normal  ovary  cannot  be 
felt  upon  the  affected  side. 

THE  BLADDER  AND  URETHRA. 

Genital  Fistula. — A  number  of  varieties  are  encountered;  the  vesico- 
vaginal and  the  rectovaginal  are  the  commonest.  Other  varieties  are: 
urethrovaginal,  vesico-uterine,  vesicoutero-vaginal,  ureterovaginal,  and 
uretero-uterovaginal. 

A  vesical  fistula  may  be  caused  by  the  delayed  or  improper  use  of  for- 
ceps in  a  difficult  labor.  It  may  follow  vaginal  hysterectomy,  cancer, 
syphilis,  tuberculosis,  or  ulceration  produced  by  a  foreign  body,  such 
as  a  pessary,  in  the  vagina. 

Symptoms. — Onset.  Difficulty  in  urination  followed  by  hematuria, 
febrile  disturbance,  and  vaginal  discharge;  after  the  sloughing  tissue  has 
been  cast  off  there  is  an  escape  of  urine  which  is  more  or  less  constant 
but  which  may  vary  according  to  the  posture  of  the  patient  and  the  site 
of  the  fistula.  The  vagina  is  excoriated  and  encrusted  with  deposits  of 
urinary  salts;  there  are  excoriations  of  the  external  genitalia  and  the 
inner  surface  of  the  thighs ;  the  urine  undergoes  ammoniacal  decomposi- 
tion and  has  a  foul  odor.  Emaciation,  depression  of  spirits,  and  general 
ill-health  occur. 

Examination:  Fistulous  openings  may  be  hard  to  find.  Smaller  fistulse 
must  be  searched  for  among  the  vaginal  folds  with  a  Sims  speculum  and 
a  probe.  A  sound  or  a  probe  in  the  bladder  may  be  passed  through  the 
fistula  or  the  bladder  may  be  distended  with  milk  or  with  methylene- 
blue  solution  while  the  anterior  vaginal  wall  is  exposed  to  view.  Large 
fistulse  are  easily  found;  they  are  surrounded  by  scar  tissue,  and  the 
vesical  mucosa  sometimes  prolapses  through  the  opening. 

Rectovaginal  fistula  may  be  caused  by  laceration  during  childbirth, 
faulty  plastic  operation,  tuberculosis,  syphilis,  or  carcinoma.  The 
fistula  permits  the  passage  of  gas  and  liquid  feces  from  the  rectum  to 
the  vagina. 

Urethritis  is  usually  due  to  gonorrhea;  highly  concentrated  urine, 
irritating  vaginal  discharges,  chemical  irritants,  and  trauma  are  predis- 
posing causes  and  sometimes  actually  produce  mild  forms. 

The  first  symptom  is  frequent  urination,  accompanied  by  burning  and 
scalding  pain,  with  the  occasional  passage  of  a  few  drops  of  blood  after 
urination.     There  is  a  purulent  discharge  from  the  urethra. 

Examination.- — The  external  meatus  is  swollen  and  red,  the  mucosa 
bulging  from  the  meatus  like  a  prolapse  of  the  urethra;  the  orifices  of 
Skene's  glands  are  conspicuous.  Pus  is  present  at  the  meatus  unless 
urination  has  recently  occurred.  Pressure  along  the  urethra  will  cause 
pus  to  appear.  The  urethroscope  shows  the  mucosa  swollen  and  red. 
In  chronic  urethritis  all  subjective  symptoms  are  absent  except  perhaps 
frequency  of  urination.  The  urethroscope  shows  small  ulcers  or  granular 
patches  with  little  or  no  swelling  of  the  mucous  membrane  between  them. 


736  GYNECOLOGICAL  DIAGNOSIS 

Urethral  caruncle  is  the  most  frequent  neoplasm  of  the  urethra.  It 
varies  from  a  pale  to  a  bright  red  color,  resembling  somewhat  a  raspberry; 
its  size  ranges  from  a  pinhead  to  a  hickory  nut.  It  is  usually  found 
on  the  posterior  wall  of  the  urethra,  just  on  the  margin  of  or  inside  the 
meatus.  The  growth  may  be  sessile  or  pedunculated,  is  exquisitely 
sensitive  to  touch,  and  bleeds  readily. 

Symptoms. — There  is  pain  during  urination  which  lessens  gradually, 
but  sometimes  lasts  for  ten  or  fifteen  minutes.  There  is  pain  also  on 
walking;  coitus  may  be  impossible.  The  suffering  may  be  so  great  and 
so  constant  that  the  general  health  is  seriously  impaired. 

Suburethral  Abscess. — There  are  the  symptoms  of  an  acute  urethritis 
together  with  the  presence  of  a  tumor  projecting  into  the  vagina  along 
the  course  of  the  urethra.  The  enlargement  is  extremely  tender  and 
upon  pressure  discharges  its  contents  into  the  urethra. 

Cystitis. — Cystitis  is  produced  by  the  extension  of  a  urethritis,  the 
trauma  and  the  infection  which  may  be  incident  to  catheterization, 
retention  of  urine  within  a  cystocele,  a  stricture  or  a  neoplasm  of  the 
urethra,  vesical  calculus,  exanthemata,  or  injuries.  The  acute  form  is 
produced  by  gonorrhea  or  infection  from  instrumentation. 

The  symptoms  are  frequent  and  painful  urination,  pain,  and  a  feeling 
of  fulness  in  the  bladder,  vesical  tenesmus,  and  slight  bleeding  at  the 
end  of  urination.  Tenderness  is  elicited  by  pressing  on  the  base  of  the 
bladder  through  the  vagina.  On  cystoscopic  examination  the  mucosa 
is  found  to  be  covered  with  a  thick,  tenacious  pus;  it  is  swollen  and  has 
a  deep  red  color.  There  may  be  partial  exfoliation  of  the  mucosa. 
Catheterized  specimens  of  urine  show  pus  and  blood.  The  subacute 
or  chronic  form  is  the  residuum  of  an  acute  attack  or  is  produced  by 
milder  grades  of  infection  with  retention  and  decomposition  of  the  urine. 
Tuberculous  cystitis  may  occur  secondary  to  tuberculosis  of  the  kidney. 

Symptoms. — There  is  more  or  less  dull  pain  in  the  bladder  region, 
frequent  and  painful  urination,  and  tenderness  on  pressure  over  the  base 
of  the  bladder.  Cystoscopic  examination  shows  the  mucosa  of  a  dirty 
or  grayish  red  color,  covered  with  mucopurulent  discharge,  and  areas  of 
erosion  or  actual  ulcers  scattered  over  it.  The  lesions  often  are  confined 
largely  to  the  vesical  trigone.  A  catheterized  specimen  of  urine  is  alka- 
line and  contains  mucus,  pus,  bladder  epithelium,  and  perhaps  blood. 

Vesical  calculus  is  less  frequent  in  women  than  in  men  because  of  the 
greater  diameter  and  shortness  of  the  urethra.  The  symptoms  of  the 
disorder  differ  in  no  wise  from  those  in  the  male.  A  large  stone  may  be 
felt  by  bimanual  palpation. 

Gonorrhea. — Gonorrhea  in  the  female  does  not  have  the  violent  initia- 
tive course  which  it  has  in  the  male.  In  sluggish  or  in  uncleanly  women 
the  disease  may  exist  for  some  time  before  being  observed;  it  usually  starts 
in  one  of  three  localities,  or  in  two  or  all  of  them  combined,  viz.,  the 
urethra,  the  vulvovaginal  glands,  and  the  cervix.  A  coincident  sup- 
purative inflammation  of  the  three  is  highly  suggestive  of  gonorrhea. 
Gonorrhea  usually  is  first  evidenced  by  the  symptoms  of  urethritis  which 
continue  for  a  few  days  and  then  subside.     Chronic  suppuration  persists . 


THE  BLADDER  AND   URETHRA  737 

in  Skene's  tubules,  the  ducts  of  the  vulvovaginal  glands,  and  the  cervix. 
Acute  vulvitis  rarely  develops  from  the  initial  infection  except  in  the 
young. 

Gonorrhea  is  most  apt  to  extend  to  the  endometrium,  and  from  there 
to  the  tubes  and  the  pelvic  peritoneum,  during  or  after  a  menstrual 
period  or  after  labor.  The  symptoms  and  the  diagnosis  of  the  various 
lesions  of  gonorrhea  (vulvitis,  cervical  catarrh,  endometritis,  salpingitis, 
peritonitis)  have  already  been  described. 

The  gonococcus  may  be  detected  in  smears  taken  directly  from  Skene's 
tubules,  the  vulvovaginal  ducts,  and  the  cervix.  Although  the  coincident 
infection  of  the  urethra,  vulvovaginal  glands,  and  the  cervix,  and  the 
presence  of  gonorrheal  macules  at  the  orifices  of  Skene's  tubules  and  the 
vulvovaginal  glands  constitute  almost  undoubted  evidence  of  gonorrhea; 
still,  in  a  forensic  sense,  at  least,  the  diagnosis  is  not  positive  until  the 
specific  organism  has  been  found. 


47 


INDEX. 


Abdomen,  contusions  of,  477 

foreign  bodies  in,  x-rays  in,  64 
Abdominal  aneurysms,  x-rays  in,  64 
examination,  700 
muscles,  rupture  of,  488 
parietes,  abscess  of,  488 
retention  of  testicle,  651 
swellings,  left  lower  quadrant,  498 

right  lower  quadrant,  497 
tumors,  486 

x-rays  in  diagnosis  of,  65 
wall,  actinomycosis  of,  488 

carcinoma  of,  489 

cellulitis  of,  487 

cysts  of,  489 

edema  of,  487 

emphysema  of,  487 

fibroma  of,  488 

grnnma  of,  488 

hernia  of,  487 

lipoma  of,  488 

sarcoma  of,  489 

swellings  of,  487 

syphilis  of,  488 
Abducens  nerve,  functions  of,  152 

paralysis  of,  152 
Abscess  of  abdominal  parietes,  488 
of  anus,  546 
of  axilla,  438 
of  brain,  169,  236 
of  buttocks,  633 
cold,  452 
of  groin,  638 
iHac,  497 
ischiorectal,  547 
of  liver,  495,  519 
of  lungs,  459 

x-rays  in,  61 
of  ovary,  727 
of  palate,  299 
palmar,  360 
of  pancreas,  526 
of  penis,  646 
perinephric,  497 

x-rays  in  diagnosis  of,  63 
peritonsillar,  296 
psoas,  497,  615 
retropharyngeal,  298 
of  roots  of  teeth,  290 
of  scrotum,  649,  650 
of  spleen,  499  ^^k 


Abscess  of  stomach,  493 

sublingual,  310 

submammary,  466 

subphrenic,  495,  499 

x-rays  in  diagnosis,[62; 

suburethral,  736 

supramammary,  466 

of  tibia,  591 

of  imibilicus,  490 

of  vulvovaginal  glands,  712 
Acetonuria,  26 
Achilles  jerk,  156 
Achondroplasia,  127 

x-rays  in  diagnosis  of,  42 
Acne,  85 

rosacea  of  nose,  273 
Acromegaly,  127 

x-rays  in  diagnosis  of,  42 
x4.cromial  bursitis,  442 
Acromioclavicular  dislocations,  x-rays  in 

diagnosis  of,  47 
Actinomycosis,  76 

of  abdominal  wall,  488 

of  cecum,  498 

of  face,  250 

of  intestines,  538 

of  jaw,  284 

of  limg,  459 

of  l3rmph  glands,  305 

of  neck,  315 

of  peritoneum,  480 

of  spine,  343 

of  tongue,  294 
Addison's  disease,  692 
Adductor  tubercle,  fracture  of,  603 
Adenitis,  acute,  310,  414 

of  axilla,  439 

cervical,  311 

chancroidal,  of  groin,  639 

chronic,  104 

phagedenic,  105 

submaxillary,  310 

submental,  310 

syphilitic,  104 

tuberculous,  105 

of  axillary  glands,  442 
of  groin,  639 
Adenoid  growths,  278 
Adenoma  of  brain,  168J 

of  face,  253 

of  lips,  281 
Adenopathy  of  neck,  gummatous,  316 
syphilitic,_316 


740 


INDEX 


Adrenal  gland,  tuberculosis  of,  692 
Alar  ligaments,  contusion  of,  599 
Albuminuria,  24 
Amastia,  464 
Amenorrhea,  697 
Amyloid  degeneration,  531 
Amytrophic  lateral  sclerosis,  197 
Anemia,  18 

pernicious,  18 
Aneurysm,  98 

of  aorta,  321,  462 
arteriovenous,  99 
of  neck,  321 
cirsoid,  99 

of  external  carotid  artery,  321 
of  femoral  artery,  616 
of  iliac  artery,  497 
of  internal  carotid  artery,  321 
of  neck,  320 
of  popliteal  artery,  609 
of  renal  arteries,  691 
of  scalp,  238,  239 
of  subclavian  artery,  321 
x-rays  in  diagnosis  of,  59 
abdominal,  64 
traumatic,  66 
Angioma,  99 

cavernous,  99 
of  conjunctiva,  263 
of  eyelids,  260 
of  foot,  579 
of  forearm,  384 
of  hand,  368 
of  lips,  280 
of  liver,  519 
of  muscles,  110 
of  nasopharynx,  279 
of  orbit,  264 
of  scalp,  238 
Angioneurotic  edema,  90,  246 

gangrene,  100 
Ankle,  bones  of,  fractures  of,  564 
inflammation  of,  575 
clonus,  156 
dislocations  of,  570 
gumma  of,  578 

joints  of,  arthritis  of,  acute,  575,  576 
chronic,  577 
post-traumatic,  577 
tuberculous,  577 
inflammation  of,  575 
sprains  of,  564 
trauma  of,  564 
Ankylosis  of  hip,  622 

of  knee,  598 
Anus,  abscess  of,  546 
chancroids  of,  549 
congenital  malformations  of,  545 
dermatitis  of,  545 
eczema  of,  545 
epithelioma  of,  550 
fissures  of,  547 
fistula  of,  548 

tuberculous,  548 
fistulous  opening  of,  547 
folliculitis  of,  546 


Anus,  papilloma  of,  549 
prolapse  of,  551 
pruritus  of,  546 
syphilis  of,  549 
tuberculosis  of,  549 
tumors  of,  549 

malignant,  550 
Anomalies  of  kidneys,  683 
of  spinal  column,  334 
of  spleen,  529 
of  testicle,  congenital,  651 
of  ureters,  679 
Anteflexion  of  cervix,  715 
Anthrax,  76,  91 
of  face,  246 
Aorta,  aneurysm  of,  321,  462 
Ape  hand,  347 
Aphasia,  motor,  142 

sensory,  144 
Aphtha?,  288 
Apoplexy,  160 
Appendicitis,  acute,  540 
chronic,  542 

diagnosis  of,  from  gonorrheal  pelvic 
peritonitis,  728 
Areola,  chancre  of,  466 
eczema  of,  466 
epithelioma  of,  466 
furuncle  of,  466 
Arm,  angioma  of,  448 

bones  of,  inflammation  of,  445 
contusions  of,  418 
fibrolipoma  of,  447 
fibroma  of,  447 
inflammations  of,  438,  441 
joints  of,  inflammations  of,  445 
lipoma  of,  447 

nerves  of,  inflammation  of,  442 
rupture  of  muscles  of,  418 
sarcoma  of,  447 
traumatism,  of,  418 
tumors  of,  447 
wounds  of,  418 
Arteriosclerosis,  x-rays  in  diagnosis  of,  66 
Arteriosclerotic  gangrene  of  hand,  365 

pain  of  foot,  561 
Arteriovenous  aneurysm,  99 

of  neck,  321 
Arteritis,  96 
Arthritis,  132 

acute  gonorrheal,  134 
gouty,  134 

of  wrist,  366 
hemophilic,  136 
infectious,  of  hip,  628 
of  joints  of  ankle,  575,  576 

of  foot,  575 
of  metatarsal  joints,  576 
of   metatarsophalangeal   joints, 

576 
post-traumatic,  of  hand,  366 

of  wrist,  366 
purulent,  of  infants,  136 
rheumatic,  134 
of  elbow,  415 
of  knee-joint,  610 


INDEX 


741 


Arthritis,  acute  rheumatoid,  of  hand,  366 
of  wrist,  366 
serous,  of  shoulder,  440 
suppurative,  of  elbow,  415 

of  shoulder,  440 
of  tarsal  joints,  576 
of    temporomaxillary    articula- 
tion, 287 
traumatic,  133 
of  elbow,  414 
of  hand,  366 
of  knee-joint,  609 
tuberculous,  135 
atrophic,  x-rays  in  diagnosis  of,  50 
chronic,  136 

of  elbow,  415 

gouty,  137 

of  joints  of  ankle,  577 

of  foot,  577 
of  shoulder,  446 
traumatic,  136 

of  knee-joint,  610 
of  wrist,  366 
tuberculous,  137 
deformans,  632 
acute,   135 
chronic,  136 
fungous,  of  shoulder,  447 
gonococcal,  of  elbow,  415 
of  hip,  628 
of  knee-joint,  610 
gonorrheal,  of  hand,  366 

of  wrist,  366 
influenza,  135 
neuropathic,  138 
of  elbow,  416 
of  knee-joint,  613 
of  shoulder,  447 
osteomyelitic,  of  hip,  629 
pneumococcic,  135 

of  hip,  629 
post-traumatic,  of  joints  of  ankle,  577 

of  foot,  577 
rheumatic,  of  elbow,  415 
of  hip,  628 

of    temporomaxillary    articula- 
tion, 287 
scarlet  fever,  135 
serofibrinous,  of  shoulder,  440 
of  spinal  column,  x-rays  in  diagnosis 

of,  58 
syphilitic,  138 
of  elbow,  415 
of  knee-joint,  612 
traumatic,  of  hip,  628 
tuberculous,  of  elbow,  415 
of  hip,  629 
of  joints  of  ankle,  577 

of  foot,  577 
of  knee-joint,  611 
of  shoulder,  447 
of    temporomaxillary    articula- 
tion, 287 
of  wrist,  367 
typhoidal,  135 
of  hip,  628 


Arthritis,  x-rays  in  diagnosis  of,  49 
Arthropathy,  syringomyelic,  138 

tabetic,  138,  579 
of  hip,  632 

x-rays  in  diagnosis  of,  53 
Aseptic  fever,  traumatic,  69 
Astragalus,  dislocations  of,  571 

fracture  of,  565 
Ataxia,  locomotor,  197 
Athelia,  464 
Atresia  of  urethra,  707 

of  vagina,  707,  713 
Atrophic  arthritis,  x-rays  in  diagnosis  of, 
50 

rhinitis,  274 
Atrophy  of  breast,  465 

of  muscles.  111 
Auditory  meatus,  furuncles  of,  255 
inflammations  of,  255 

nerve,  functions  of,  152 
Auricle,  congenital  deformities  of,  254 
Axilla,  abscesses  of,  438 

adenitis  of,  439 

carcinoma  of,  448 

eczema  of,  438 

lipoma  of,  448 

l3miphangioma  of,  448 

sarcoma  of,  448 

tinea  of,  438 
Axillary    glands,    inflammatory    hyper- 
plasia of,  442 
tuberculous  adenitis  of,  442 


Bacteriuria,  671 
Balanoposthitis,  642 
Banti's  disease,  531 
Baj^onet  finger,  351 
Bell's  palsy,  216 
Bence-Jones'  body  in  urine,  25 
Biceps  bursitis,  608 

clonus,  156 

muscle,  syphilis  of,  441 

reflex,  156 
Bicornate  uterus,  720 
Bile  pigment  in  urine,  27 
Biliary  calculus,  x-rays  in,  64 
Birth  injuries  of  head,  227 
Bladder,  calculi  of,  675 

carcinoma  of,  678 

centres  of  spinal  cord,  193 

contusion  of,  673 

exstrophy  of,  672 

foreign  bodies  in,  678 
x-ra3rs  in,  64 

hernia  of,  672 

inflammation  of,  674 

malformations  of,  671 

malpositions  of,  671 

rupture  of,  673 

trauma  of,  673 

tuberculosis  of,  678 

tumors  of,  494,  678 

wounds  of,  673. 


742 


INDEX 


Blastomycotic  ulcers  of  leg,  583 
Blepharitis,  259 
Blindness,  letter,  144 

word,  144 
Blood,  coagulation  of,  17 
cysts  of  neck,  318 
effusions,  diffuse,  491 
examination  of,  17 
in  urine,  26 
Bloodvessels,  contusions  of,  96 
inflammation  of,  96 
rupture  of,  96 
trauma  of,  96 
tumors  of,  99 
wounds  of,  96 
Bones,  118 

of  ankle,  fracture  of,  564 

inflammation  of,  575 
of  arm,  inflammation  of,  445 
carcinoma  of,  130 

a;-rays  in  diagnosis  of,  45 
chondroma  of,  128 
contusion  of,  1 18 
cranial,  fracture  of,  227 

gumma  of,  234 

indentation  of,  227 
cysts  of,  130 

a;-rays  in  diagnosis  of,  44 
disease  of,  fat  embolus  and,  130 

a;-rays  in  diagnosis  of,  37 
endothelioma  of,  129 
fibrochondroma  of,  117 
fibroma  of,  130 
of  fingers,  dislocations  of,  357 

fractures  of,  352 
of  foot,  fractures  of,  564 

inflammation  of,  575 
fracture  of,  118 

unimited,  120 
of  hand,  dislocation  of,  357 

fractures  of,  352 

inflammations  of,  366 
hyoid,  fracture  of,  308 
hypernephroma  of,  130 
inflammation  of,  120,  122 

a;-rays  in  diagnosis  of,  39 
of  leg,  fracture  of,  584 

inflammation  of,  587 
lipoma  of,  128 
malar,  fracture  of,  245 
myeloma  of,  129 
osteoma  of,  127 
Paget's  disease  of,  127 
sarcoma  of,  129 

x-rays  in  diagnosis  of,  41,  43 
of  shoulder,  inflammation  of,  445 
of  skull,  fracture  of,  227 
syphilis  of,  hereditary ,  x-rays  in  diag- 
nosis of,  42 

x-rays  in  diagnosis  of,  40 
trauma  of,  118 
tuberculosis  of,  x-rays  in  diagnosis  of, 

39 
tumors  of,  127 

x-rays  in  diagnosis  of,  43 
of  wrist,  dislocations  of,  357 


Bones  of  wrist,  fractures  of,  352 

inflammations  of,  366 
^-oxybutyric  acid  in  urine,  26 
Brachial  neuralgia,  220 
neuritis,  219 
palsy,  220 

plexus,  contusions  of,  308 
Brain,  abscess  of,  169,  236 
adenoma  of,  168 
carcinoma  of,  167 
cholesteatoma  of,  168 
compression  of,  185,  225 
concussion  of,  224 
contusions  of,  223 
cysts  of,  168 

traumatism  and,  168 
diseases  of,  135 

alterations  in  mentality  in,  163 

apoplexy  in,  160 

convulsions  in,  154 

disturbance  of  motility  in,  153 
of  sensation  in,  162 
of  special  senses  in,  163 
of  vision  in,  163 

dizziness  in,  153 

epilepsy  in,  154 

forced  movements  in,  154 

headache  in,  153 

hemiplegia  in,  158 

idiocy  in,  163 

imbecility  in,  163 

insanity  in,  163 

nausea  in,  153 

paralysis  in,  155 

reflexes  in,  155 

tremors  in,  154 

vertigo  in,  153 

vomiting  in,  153 
endothelioma  of,  164 
fibroma  of,  167 
frontal  lobe  of,  tumors  of,  171 
glioma  of,  165 
gumma  of,  166 
injuries  of,  185 

terminal  effects  of,  187 
internal  capsule  of,  145 
lipoma  of,  168 

meninges  of,  diseases  of,  201 
motor  centres  of,  142 

tumors  of,  174 
occipital  area  of,  tumors  of,  176 
osteoma  of,  168 
osteosarcoma  of,  164 
psammoma  of,  168 
psychical  centres  of,  144 
sarcoma  of,  164 
sensory  centres  of,  142 

timiors  of,  175 
subcortical  centres  of,  145 

timiors  of,  178 
syphilis  of,  166 

temporal  lobes  of,  tumors  of,  177 
tuberculosis  of,  165 
tumors  of,  163 

x-rays  in  diagnosis  of,  55 
visual  centres  of,  144 


INDEX 


743 


Brain,  visual  centres  of,  tumors  of,  176 
Branchial  cysts,  317 

fistute,  306 
Breast,  abscess  of,  464,  466 

actinomycosis  of,  464 

atrophy  of,  465 

chancre  of,  464,  466 

cysts  of,  468 

diseases  of,  general  symptomatology 
of,  464 

ecchymosis  of,  470 

eczema  of,  464,  466 

epithelioma  of,  464,  466 

erosion  of,  464 

fissure  of,  464,  466 

furuncle  of,  466 

gumma  of,  464,  468 

hypertrophy  of,  465 

iiiflammation  of,  467 

malformations  of,  464 
congenital,  464 

syphilis  of,  468 

tuberculosis  of,  464,  468 

tumors  of,  464,  468 
Bronchi,  foreign  bodies  in,  323 

x-rays  in  diagnosis  of,  59 
Bronchiectasis,  459 
Brown-Sequard  paralysis,  200 
Bunion,  x-rays  in  diagnosis  of,  54 
Burns  of  larynx,  323 
Bursse,  115 

enchondroma  of,  117 

gimama  of,  116 

inflammation  of,  115 

myxoma  of,  117 

sarcoma  of,  117 

of  shoulder,  inflammation  of,  442 

subdeltoidean,  inflammation  of, 
acute  suppurative,  439 

subhyoid,  319 

suprahyoid,  319 

syphilis  of,  116 

tuberculosis  of,  116 

tumors  of,  117 
Bursitis,  115 

acromial,  442 

acute,  115 

biceps,  608 

chronic,  116 

of  elbow,  acute,  414 
chronic,  414 

gastrocnemius  -  semimembranous, 
607 

gummatous,  116 

ileopsoas,  628 

infrapatellar,  607 

ischiatic,  628 

of  knee-joint,  607 

popliteal,  608 

prepatellar,  acute,  607 
chronic,  607 
tuberculous,  607 

pretibial,  607 

retrocalcaneal,  574 

subcoracoid,  445 

subdeltoidean,  442 


Bursitis,  syphilitic,  116 
trochanteric,  628 
tuberculous,  116 
x-rays  in,  66 

Buttocks,  abscess  of,  633 
contusions  of,  633 
sarcoma  of,  633 
wounds  of,  633 


Calcaneum,  fractures  of,  565 
Calculi,  biliary,  x-rays  in,  64 

nasal,  273 

of  pancreas,  527 

of  parotid  gland,  301 

of  prostate,  663 

x-rays  in  diagnosis  of,  63 

renal,  684 

x-rays  in  diagnosis  of,  62 

salivary,  291 

x-rays  in  diagnosis  of,  55 

ureteral,   680 

vesical,  675,  736 

x-rays  in  diagnosis  of,  63i 
Callosities,  94 
Cancer.     See  Carcinoma. 

en  cuirasse,  461 
Capillary  hemorrhoids,  551 
Caput  succedanemn,  227 
Carbolic  acid  gangrene  of  hand,  365 
Carbuncle,  91 

of  face,  245 
Carcinoma  of  abdominal  wall,  489 

of  axilla,  448 

of  bladder,  678 

of  bone,  130 

x-rays  in  diagnosis  of,  45 

of  brain,  167 

of  cecum,  498 

of  cervix,  717 

of  duodenum,  515 

of  eyelids,  260 

of  gall-bladder,  523 

of  humerus,  449 

of  inguinal  glands,  639 

of  intestines,  499,  537 

of  jaw,  286 

of  lar3Tix,  325 

of  liver,  495,  519 

of  maxillary  sinus,  276 

of  neck,  314 

of  orbit,  265 

of  pancreas,  527 

of  peritoneum,  481 

of  rectum,  555 

of  salivary  gland,  305 

of  scalp,  241 

of  spine,  343 

of  spleen,  531 

of  stomach,  514 

of  thigh,  618 

of  thorax,  460 

of  thyroid  gland,  330 

of  tongue,  294 


744 


INDEX 


Carcinoma  of  tonsils,  298 

of  tympanmn,  257 

of  umbilicus,  489 

of  ureter,  682 

of  uterus,  722 

of  vagina,  714 

of  vulva,  710 
Cardiospasm,  473 

with  diffuse  dilatation  of  esophagus, 
474 
Caries  of  teeth,  289 

of  vertebrse,  a;-rays  in  diagnosis  of, 
57 
Carotid  arteries,  aneurysm  of,  321 

body,  316 

tumor,  306 
Carpal  bones,  dislocations  of,  358 

a;-rays  in  diagnosis  of,  47 
fractures  of,  354 
Caruncle,  urethral,  736 
Catarrh  of  cervix,  717 
Catarrhal  pancreatitis,  526 

proctitis,  acute,  550 
Cauda  equina,  191 

tumors  of,  206 
Cavernitis  of  penis,  641 
Cavernous  angioma,  99 

bodies,  induration  of,  648 
Cecum,  actinomycosis  of,  498 

carcinoma  of,  498 

tuberculosis  of,  498 
Celiotomy,    postoperative    complications 

of,  79 
Cellulitis,  75 

of  abdominal  wall,  487 

of  fingers,  359 

of  forearm,  382 

of  hand,  358 

of  leg,  583 

of  penis,  641 

peritendinous,  112 

of  scrotum,  649,  651 

of  thorax,  451 
Cephalhematoma,  227 
Cephalocele,  243 
Cerebellum,  147 

tumors  of,  179 
Cerebral  pachymeningitis,  201 

peduncles,  145 

serous  meningitis,  204 
Cerebrospinal  meningitis,  202 
Cervical  adenitis,  311 

nerves,  diseases  of,  219 

neuralgia,  219 

rib,  308,  334 

x-rays  in  diagnosis  of,  54 
Cervix,  anteflexion  of,  715 

carcinoma  of,  717 

catarrh  of,  717 

cystic  degeneration  of,  716 

double,  715 

aversion  of,  716 

infantile,  715 

inflammation  of,  717 

lacerations  of,  716 

malformations  of,  715 


Cervix,  newgrowths  of,  717 

pedunculated  fibroid  timiors  of,  717 

polyps  of,  717 

sarcoma  of,  719 

septate,  715 

venereal  warts  of,  717 
Chalazion,  259,  260 
Chancre  of  areola,  466 

of  breast,  464,  466 

of  conjimctiva,  263 

of  eyelids,  259 

of  face,  247 

of  hand,  362 

of  lips,  279 

of  nipple,  466 

of  nose,  273 

of  penis,  644 

of  tongue,  293 

of  tonsils,  297 

of  vulva,  709 
Chancroidal  adenitis  of  groin,  639 

urethritis,  669 
Chancroids  of  anus,  549 

of  penis,  645 

of  vulva,  709 
Charcot-Leyden  crystals,  32 
Chilblain  of  foot,  561 
Choked  disk,  151 
Cholangitis,  fever  of,  74 
Cholasma,  94 
Cholecystitis,  521 
Cholelithiasis,  521 
Cholesteatoma  of  brain,  168 

of  ear,  257 
Chondroma  of  bone,  128 

of  foot,  579 

of  jaw,  285 

of  nasopharynx,  279 

of  rib,  461 

of  sacro-iliac  joint,  637 

of  salivary  gland,  304 

of  skull,  242 

of  sternum,  461 
Chorio-epithelioma  of  uterus,  726 
Chylothorax,  458 

Circumflex  nerve,  paralysis  of,  221 
Cirsoid  aneurysm,  99 
Clavicle,  dislocations  of,  438 

fractures  of,  433 

gummatous  osteitis  of,  446 
Claw  hand,  347 
Cloaca,  persistent,  707 
Club  foot,  560 
Coccygodynia,  634 
Coccyx,  cysts  of,  333 

tumors  of,  333 
Cold  abscess,  452 
CoUes'  fracture,  355 
Colon,  diseases  of,  a:-rays  in,  66 
Compression  of  brain,  i85,  225 
Concussion  of  brain,  224 

of  chest,  453 
Condyles  of  femur,  fracture  of,  602 
Condyloid  fractures,  397 
Congenital  anomalies  of  intestines,  534 
of  testicle,  651 


INDEX 


745 


Congenital  anomalies  of  umbilicus,  489 
cysts  of  brain,  168 

of  neck,  318 

of  salivary  glands,  304 
deformities  of  auricle,  254 

of  nose,  272 
dislocations  of  hip,  621 

rc-rays  in  diagnosis  of,  47,  54 

of  joints,  132 
fistula  of  auricle,  254 
macroglossia,  294 
malformations  of  anus,  545 

of  breast,  464 

of  esophagus,  472 

of  hand,  346 

of  kidney,  497 

of  neck,  306 

of  peiiis,  640 

of  rectum,  545 

of  thorax,  451 
sacrococcygeal  timaors,  633 
torticollis,  307 
tumors  of  neck,  307 
wry-neck,  307 
Congestion  of  spleen,  530 
of  thyroid  gland,  327 
of  tympanum,  255 
Conjunctiva,  angioma  of,  263 
chancre  of,  263 
cysts  of,  263 
hyperemia  of,  261 
iiiflammation  of,  261 
lipoma  of,  263 
polyps  of,  263 
timiors  of,  263 
xerosis  of,  263 
Conjunctivitis,  261 

acute  contagious,  261 
catarrhal,  261 
diphtheritic,  262 
diplobacillus,  262 
follicular,  263 
gonorrheal,  262 
granular,  263 
phlyctenular,  263 
simple,  261 
Constipation  fever,  73 
Contracture  of  hip,  622 

of  internal  vesical  sphincter,  664 
of  muscles,  111 
Contusions  of  abdomen,  477 
of  alar  ligaments,  599 
of  arm,  418 
of  bladder,  673 
of  bloodvessels,  96 
of  bones,  118 
of  brachial  plexus,  308 
of  brain,  223 
of  buttocks,  633 
of  chest,  453 
of  ear,  254 
of  eye,  268 
of  face,  245 
of  foot,  564 
of  hand,  346,  348 
of  hip,  623 


Contusions  of  kidney,  684 
of  knee,  598 
of  larynx,  308,  322 
of  leg,  584 
of  muscles,  107 
of  neck,  308 
of  nose,  272 
of  orbit,  263 
of  penis,  640 
of  scalp,  223 
of  scrotum,  649 
of  shoulder,  418 
of  spine,  336 
of  stomach,  510 
of  testicle,  653 
of  thigh,  614 
Conus  meduUaris,  190 
Convulsions,  154 

Jacksonian,  154 
Cornea,  foreign  bodies  in,  266 
inflammation  of,  266 
ulcerations  of,  266 
Corset  liver,  518 
Cortical  localization,  142 
Coryza,  273 

Costal  cartilages,  fracture  of,  455 
Cowperitis,  668 
Coxa  valga,  622 
vara,  622 

.T-rays  in  diagnosis  of,  54 
Cranial  bones,  fracture  of,  227 
gumma  of,  234 
indentation  of,  227 
nerves,  148 

diseases  of,  215 
Cranium.     See  Skull. 
Cretinism,  326 

Crucial  ligaments,  rupture  of,  599 
Cruroscrotal  retention  of  testicle,  652 
Crus,  145 

tumors  of,  178 
Crutch  palsy.  111 
Cryoscopy,  24 
Curvature  of  spine,'  335 

lateral,  335 
Cutaneous  horns  of  eyelids,  260 

of  face,  253 
Cystic  degeneration  of  cervix,  716 
of  ovary,  731 
goitre,  320 
Cystitis,  674,  736 
Cystocele,  715 

Cysts  of  abdominal  wall,  489 
of  bone,  130 

x-rays  in  diagnosis  of,  44 
of  brain,  168 
of  breast,  468 
of  coccyx,  334 
of  conjunctiva,  263 
of  epididymis,  656 
epithelial,  of  foot,  579 

of  band,  368 
of  esophagus,  474 
of  face,  252 
of  jaw,  285 
of  kidney,  691 


748 


INDEX 


Cj^sts  of  labial  glands,  281 
of  larynx,  325 
of  lips,  281 
of  liver,  519 
of  lungs,  459 
of  maxillary  sinus,  276 
of  mesentery,  493 
of  muscles,  110 
of  neck,  317 
of  omentum,  493 
of  orbit,  265 
of  ovary,  734 

accidents  to,  734 
of  palate,  299 
of  pancreas,  527 
parovarian,  734 
of  penis,  469 
retroperitoneal,  492 
of  sacrxma,  334 
of  salivary  glands,  304 

congenital,  304 
of  scalp,  240 
of  scrotum,  650 
of  seminal  vesicles,  662 
of  skull,  243 
of  spinal  cord,  206 
of  spleen,  499,  531 
of  suprarenal  gland,  692 
of  testicle,  656 
of  thigh,  615 
of  thyroid  gland,  331 
of  tongue,  296 
of  urachus,  489 
of  vagina,  714 
of  vulvovaginal  glands,  713 


Dacrocystitis,  261 
Dactylitis  syphilitica,  363 

aj-rays  in  diagnosis  of,  42 
Deformities  of  foot,  556 

of  knee,  597 
Degeneration  of  spleen,  531 
Dental  caries,  289 
Dentigerous  cysts  of  bone,  130 

of  jaw,  285 
Dermatitis  of  anus,  545 
of  foot,  562 
of  hand,  360 
of  penis,  641 
Dermoid  cysts  of  face,  252 

of  liver,  519 

of  neck,  318 

of  orbit,  266 

of  ovary,  734 

of  penis,  648 

of  skull,  243 

of  spleen,  531 

of  tongue,  296 
Diabetic  gangrene,  100 

of  hand,  365 
Diacetic  acid  in  urine,  26, 
Diaphragmatic  hernia,  507 
Dilatation  of  stomach,  acute,  511 


Diphtheritic  conjunctivitis,  262 

laryngitis,  323 

proctitis,  550 

rhinitis,  273 

tonsillitis,  297 

urethritis,  669 
Diplobacillus  conjunctivitis,  262 
Dislocations  of  ankle,  570 

acromioclavicular,  x-rays  in  diagnosis 
of,  47 

of  astragalus,  571 

of  carpal  bones,  358 

x-rays  in  diagnosis  of,  47 

of  clavicle,  438 

of  elbow-joint,  408 

x-rays  in  diagnosis  of,  47 

of  fibula,  606 

of  foot,  570 

of  forearm,  forward,  412 
lateral,  412 

of  hand, 357 

of  hip,  626 

congenital,  621 

x-rays  in  diagnosis  of,  47, 
54 
traumatic,  x-rays  in  diagnosis  of, 
47 

of  humerus,  435 

of  jaw,  287 

of  joints,  131 

congenital,  132 

of  knee-joint,  606 

of  OS  magnum,  358 

of  penis,  641 

of  radial  styloid,  358 

radiocarpal,  357 

radio-ulnar,  358 

of  radius,  412 

of  semilunar  bone,  358 

of  shoulder- joint,  435 

x-rays  in  diagnosis  of,  47 

of  spine,  336 

of  sternum,  x-rays  in  diagnosis  of, 
57 

subastragaloid,  571 

of  tarsus,  x-rays  in  diagnosis  of,  49 

of  tendons,  112 
of  foot,  572 

of  testicle,  653 

of  tibia,  606 

tibiotarsal,  572 

of  ulna,  412 

of  ulnar  styloid,  358 

of  wrist,  357 

x-rays  in  diagnosis  of,  46 
Displacements  of  uterus,  720 
Diverticula  of  esophagus,  475 

of  intestines,  538 
Duchenne-Erb's  paralysis,  220 
Duodenum,  carcinoma  of,  515 

ulcer  of,  515 
Dupuytren's  contracture,  346 
Dural  sinuses,  inflammation  of,  235 
Dynamic  ileus,  481 
Dysenteric  proctitis,  550 
Dysmenorrhea,  698 


INDEX 


747 


E 


Ear,  auditory  meatus,  furuncles  of,  255 
inflammation  of,  255 
auricle  of,  congenital  deformities  of, 
254 
fistula  of,  254 
tumors  of,  254 
cholesteatoma  of,  257 
contusions  of,  254 
exostoses  of,  256 
foreign  bodies  in,  255 
malformations  of,  254 
middle,  inflammations  of,  256 
polyps  of,  256 
tumors  of,  256 

tympanic  membrane  of,  cancer  of, 
257 
congestion  of,  255 
polypi  of,  257 
woimds  of,  254 
wounds  of,  254 
Ecchymosis  of  breast,  470 
Echinococcus  cysts  of  bone,  130 
of  brain,  168 
of  face,  253 
of  liver,  495,  519 
of  lungs,  459 
of  muscles,  110 
of  spleen,  499 
of  thyroid  gland,  331 
Eczema,  84 

of  anus,  545 
of  areola,  466 
of  axilla,  438 
of  foot,  562 
of  nipple,  466 
of  nose,  273 
of  penis,  641 
of  scrotum,  649 
of  imabilicus,  490 
Edema  of  abdominal  wall,  487 
of  glottis,  322 
of  scrotimi,  649 
Eighth  nerve,  fimctions  of,  152 
Elbow,  386 

bursitis  of,  414 
deformities  of,  389 
dislocations  of,  408 
fractures  about,  393 
inflammations  of,  414 
sprains  of,  393 
traumatism  of,  390 
wounds  of,  390 
Elbow-joint,  arthritis  of,  acute,  414 
gonococcal,  415 
rheumatic,  415 
suppurative,  415 
traumatic,  414 
chronic,  415 
neuropathic,  416 
syphilitic,  415 
tuberculous,  415 
dislocations  of,  a;-rays  in  diagnosis 

of,  47 
inflammation  of,  414 


Elephantiasis  of  nose,  273 

of  penis,  647 

of  scalp,  239 

of  vulva,  708 
Eleventh  nerve,  functions  of,  153 
Embolic  gangrene,  100 

of  hand,  366 
Embolism,  96 
Emphysema  of  abdominal  wall,  487 

of  scrotum,  649 
Empyema  of  frontal  sinus,  277 

x-rays  in  diagnosis  of,  62 
Encephalocele,  243 

of  orbit,  266 
Encephalocystocele,  243 
Encephalohydrocele,  traumatic,  230 
Enchondroma  of  bursa,  117 

of  hand,  369 

of  maxillary  sinus,  276 

of  muscles,  110 

a;-rays  in  diagnosis  of,  45 
Endocarditis,  acute  ulcerative,  fever  of, 73 
Endometritis,  acute,  721 

chronic,  722 
Endothelioma  of  bone,  129 

of  brain,  164 
Enteritis,  485 

Epicondyle,  fractures  of,  400 
Epiconus,  191 
Epididymis,  cysts  of,  656 

inflammation  of,  654 

tuberculosis  of,  657 
Epididjonitis,  urethral,  654 
Epilepsy,  154 

grand  mal,   154 

petit  mal,  155 

psychic,  155 
Epiphora,  260 

Epiphyseal  separations,  x-rays  in  diag- 
nosis of,  39 
Epiphysitis,  acute,  x-rays  in  diagnosis  of, 

39 
Epispadia,  667,  707 
Epistaxis,  271 
Epithelial  cysts  of  foot,  579 

of  hand,  368 
Epithelioma  of  anus,  550 

of  areola,  466 

of  eyelids,  260 

of  face,  250 

benign  cystic,  253 

of  hand,  370 

of  lips,  280 

of  mouth,  289 

of  nipple,  466 

of  nose,  275 

of  penis,  647 

of  scalp,  241 

of  scrotum,  652 

of  skin,  95 

of  thorax,  461 
Epitheliomatous  ulcers  of  hand,  365 
Epulis,  285 
Erysipelas  75,  91 

of  face,  246 

of  foot,  562 


748 


INDEX 


Erysipelas  of  leg,  583 

of  nose,  272 

of  penis,  641 

of  scalp,  233 
Erysipeloid,  91 

of  foot,  562 

of  hand,  360 
Erythema  intertrigo  of  foot,  561 
of  penis,  641 
of  scrotum,  649 

multiforme  of  foot,  561 

of  nose,  273 
Erythematous  lesions  of  skin,  91 
Erythrasma,  89 
Esophagismus,  473 
Esophagitis,  acute,  472 
Esophagus,  congenital  malformations  of, 
472 

cysts  of,  474 

dilatation  of,  cardiospasm  with,  474 

diseases  of,  471 

x-rays  in  diagnosis  of,  65 

diverticula  of,  475 

foreign  bodies  in,  473 

a;-rays  in  diagnosis  of,  58 

inflammation  of,  472 

papilloma  of,  474 

polypi  of,  475 

rupture  of,  472 

stricture  of,  474 

syphilis  of,  474 

tuberculosis  of,  474 
.   ulcers  of,  474 

varices  of,  474 
Ethmoid  cells,  inflammation  of,  277 
Eversion  of  cervix,  716 
Exostoses  of  ear,  256 

of  femur,  613 

of  foot,  579 

of  orbit,  264  _ 

of  sacro-iliac  joint,  637 

of  spine,  343 

of  tibia,  613 
Exstrophy  of  bladder,  672 
Exudates,  examination  of,  34 
Eye,  contusion  of,  268 

foreign  body  in,  268 

x-rays  in  diagnosis  of,  54 

muscles  of,  paralysis  of,  268 
Eyelids,  acute  chalazion,  259 

angioma  of,  260 

blepharitis  of,  259 

carcinoma  of,  260 

chancre  of,  259 

cutaneous  horns  of,  260 

epithelioma  of,  260 

furuncle  of,  259 

herpes  of,  259 

lupus  of,  259 

milium  of,  259 

molluscum  contagiosum  of,  260 

papilloma  of,  260 

plexiform  neuroma  of,  260 

sarcoma  of,  260 

stye,  259 

xanthoma  of,  260 


Face,  actinomycosis  of,  250 

adenoma  of,  253 

anthrax  of,  246 

carbuncle  of,  245 

chancre  of,  247 

contusion  of,  245 

cutaneous  horns  of,  253 

cysts  of,  dermoid,  252 
echinococcus,  253 
sebaceous,  252 

epithelioma  of,  250 
benign  cystic,  253 

erysipelas  of,  246 

fibroma  of,  251 

furuncle  of,  245 

glanders  of,  246 

gumma  of,  248 

hemangioma  of,  251 

inflammations  of,  245 

lipoma  of,  251 

lymphangioma  of,  252 

malformations  of,  244 

neuralgia  of,  253 

sarcoma  of,  252 

skin  lesions  of,  245 

syphilis  of,  248 

tuberculosis  of,  247 

tuberculous  sinus  of,  247 

tumors  of,  250 
Facial  nerve,  functions  of,  152 
paralysis  of,  152 

neuralgia,  253 

palsy,  216 

spasm,  216 

tic,  216 
Fallopian  tube,  elongation  of,  726 
inflammation  of,  727 
malformations  of,  726 
twisting  of,  726 
Fat  embolus,  diseases  of  bone  and,  130 
Feces,  examination  of,  28 

impaction  of,  539,  552 
Femoral  artery,  aneurysm  of,  616 

epiphysis,  separation  of,  603 

hernia,  505 
Femur,  condyles  of,  fracture  of,  602 

fracture   of,    602 

neck  of,  fracture  of,  624 

shaft  of,  fracture  of,  616 
osteomyelitis  of,  617 
Fever,  68 

of  acute  ulcerative  endocarditis,  73 

of  cholangitis,  74 

constipation,  73 

of  follicular  tonsillitis,  73 

hectic,  73 

of  osteomyelitis,  73 

of  otitis  media,  73 

of  thrombosis  of  kidnej^,  73 

traumatic  aseptic,  69 
Fibrin  in  urine,  25 
Fibrochondroma  of  bursa,  117 
Fibroids  of  cervix,  717 

of  uterus,  724 


INDEX 


749 


Fibrolipoma  of  arm,  447 
Fibrol^rmphangioma  of  scalp,  239 
Fibroma  of  abdominal  wall,  488 

of  arm,  447 

of  bone,  130 

of  brain,  167 

of  face,  251 

of  jaw,  285 

of  larynx,  325 

of  maxillary  sinus,  276 

of  nasopharynx,  278 

of  neck,  317 

of  nerves,  222 

of  salivar}^  gland,  304 

of  scalp,  239 

of  spinal  cord,  206 

of  tendons,  115 

of  thorax,  460 

of  tongue,  295 
Fibromyoma  of  vagina,  714 

of  vulva,  712 
Fibrosarcoma  of  hand,  369 

of  tendons,  115 
Fibula,  dislocation  of,  606 

fracture  of,  584 

inflammation  of,  587 

tuberculosis  of,  592 
Fifth  nerve,  functions  of,  152 

paralysis  of,  152 
Fingers,  bones  of,  dislocations  of,  358 
fractures  of,  352 

cellulitis  of,  359 

inflammations  of,  359 

sprains  of,  349 
Fissures  of  anus,  547 

of  breast,  464,  466 

of  nipple,  466 
Fistula  of  anus,  548 

tuberculous,  548 

of  auricle,  congenital,  254 

branchial,  306 

genital,  735 

laryngeal,  324 

rectovaginal,  714,  735 

salivary,  305 

of  ureter,  681 

vesical,  735 
Flat  foot,  560 
Flipper  hand,  348 
Floating  liver,  494 

spleen,  499 
Focal  irritation,  224 
Follicular  tonsillitis,  fever  of,  73 
Folliculitis  of  anus,  546 
Foot,  angioma  of,  579 

arteriosclerotic  pain  of,  561 

bones  of,  fractures  of,  564 
inflammation  of,  575 

chilblain  of,  561 

chondroma  of,  579 

club,  560 

contusions  of,  564 

cysts  of,  epithelial,  579 

deformities  of,  556 

dermatitis  of,  562 

dislocations  of,  570 


Foot,  eczema  of,  562 

erj'sipelas  of,  562 
I  erysipeloid  of,  562 

erythema  of,  561 
exostoses  of,  579 
flat,  560 

gangrene  of,  563 
hollow,  560 

joints  of,  arthritis  of,  acute,  575 
chronic,  577 
post-traumatic,  577 
tuberculous,  577 
keratosis  of,  562 
lipoma  of,  579 
lupus  of,  563 
lymphedema  of,  562 
Madura,  563 
painful,  560 
sarcoma  of,  563,  579 
sprains  of,  564 
tendons  of,  dislocation  of,  572 

rupture  of,  574 
trauma  of,  564 
tumors  of,  579 
ulcers  of,  563 

gummatous,  563 
perforating,  563 
urticaria  of,  562 
Forearm,  angioma  of,  384 
cellulitis  of,  382 
dislocations  of,  412 
fractures  of,  379 

of  both  bones,  380 
inflammations  of,  382 
lipoma  of,  384 
lymphangitis  of,  382 
malformations  of,  370 
muscles  of,  rupture  of,  371 
neurofibroma  of,  384 
osteomyelitis  of,  383 
sarcoma  of,  384 
syphilis  of,  383 
tendons  of,  rupture  of,  371 
traumatisms  of,  371 
tuberculosis  of,  384 
tumors  of,  384 
wounds  of,  379 
Foreign   bodies   in   abdomen,    x-rays   in 
diagnosis  of,  64 
in  bladder,  678 

x-rays  in  diagnosis  of,  64 
in  bronchi,  323 

x-rays  in  diagnosis  of,  59 
in  cornea,  266 
in  ear,  255 
in  esophagus,  473 

x-rays  in  diagnosis  of,  58 
in  eye,  268 

x-rays  in  diagnosis  of,  54 
in  head,  x-rays  in  diagnosis  of, 

54 
in  lar3mx,  323 

x-rays  in  diagnosis  of,  59 
in  nose,  273 

in  orbit,  x-rays  in^diagnosis  of, 
54 


750 


INDEX 


Foreign  bodies  in  parotid  gland,  302 

in  pelvis,  x-rays  in  diagnosis  of, 
64 

in  pharynx,  298 

in  rectum,  552 

in  stomach,  511 

in  submaxillary  gland,  306 

in  trachea,  323 

x-vasys,  in  diagnosis  of,  59 

in  urethra,  667 
Fourth  nerve,  paralysis  of,  152 
Fractures,  118 

of  adductor  tubercle,  603 
of  astragalus,  565 
of  bones  of  ankle,  564 

of  fingers,  352 

of  foot,  564 

of  hand,  352 

of  leg,  584 

of  wrist,  352 
of  calcaneum,  565 
of  carpal  bones,  354 
of  clavicle,  433 
CoUes',  355 
condyloid,  397,  400 
of  coronoid  process  of  ulna,  405 
of  costal  cartilages,  455 
of  cranial  bones,  227 
of  elbow,  393 
of  epicondyle,  400 
of  femur,  602 

neck,  624 

shaft,  616 
of  fibula,  584 
of  forearm,  379 
of  hip,  624 
of  hiunerus,  395 

head,  421 

neck,  422,  423 

shaft,  419 

tuberosities,  422,  424 
of  hyoid  bone,  308 
intercondyloid,  402 
of  jaw,  281 
of  knee,  600 
of  larynx,  308,  322 
of  lower  extremity  of  radius,  357 
of  malar  bones,  245 
of  malleolus,  569 
of  metacarpal  bones,  353 
of  nose,  272 
of  olecranon,  405 
of  orbit,  264 
of  patella,  600 
of  pelvis,  635 
of  penis,  640 
Pott's,  568 
of  radius,  380 

head,  405 

lower  extremity,  355 

neck,  405 
of  ribs,  454 

x-rays  in  diagnosis  of,  56 
of  scapula,  430 

acromion  process,  433 

coracoid  process,  433 


Fractures  of  scapula,  neck  of,  433 
of  skuU,  227 

anterior  fossa,  228 
at  base,  186,  228 
middle  fossa,  229 
posterior  fossa,  230 
of  vault,  227 
of  spine,  336 
of  sternum,  454 

x-rays  in  diagnosis  of,  57 
supracondyloid,  396,  402 
supramalleolar,  569 
of  tarsal  scaphoid,  565 
of  tibia,  584,  604 
of  ulna,  380 
of  ulnar  styloid,  357 
ununited,  118 

of  vertebrae,  x-rays  in  diagnosis  of,  57 
x-rays  in  diagnosis  of,  37 
Fragilitas  ossiima,  x-rays  in  diagnosis  of, 

42 
Freckles,  94 

Frontal  lobe,  tumors  of,  171 
sinus,  empyema  of,  277 
inflammation  of,  276 
tumors  of,  277 
Fungous  synovitis,  114 
Furuncle,  91 

of  areola,  466 

of  auditory  meatus,  255 

of  eyelid,  259 

of  face,  245 

of  hand,  358 

of  nose,  272 

of  scalp,  232 


G 


Galactocele,  468 
Gall-bladder,  carcinoma  of,  523 

diseases  of,  x-rays  in,  64 

distention  of,  520 

injuries  of,  520 

stones  in,  521 

tmnors  of,  496 
Ganglion  of  hand,  368 
Gangrene,  angioneurotic,  100 

arteriosclerotic,  of  hand,  365 

carbolic  acid,  of  hand,  365 

diabetic,  100,  365 

emboUc,  100,  366 

of  foot,  563 

of  lungs,  459 

x-rays  in  diagnosis  of,  61 

senile,  100,  365 

symmetrical,  365 

traimiatic,  99,  365 
Gangrenous  stomatitis,  289 
Gastric  contents,  examination  of,  33 
Gastritis,  acute,  485 

chronic,  485 

sclerosing,  515 
Gastrocnemius-semimembranous  bursitis, 

608 
Gastro-enteritis,  485 


INDEX 


751 


Gastroptosis,  512 
Genital  fistula,  735 
Genu  recurvatmn,  597 

valgum,  597 

x-rays  in  diagnosis  of,  54 

varum,  598 

a;-rays  in  diagnosis  of,  54 
Gingivitis,  291 
Glanders,  77,  246 

Glands  of  neck,  inflammation  of,  319 
Glandular  cysts  of  ovary,  732 
Glans  clitoris,  adhesions  of  prepuce  to, 

70S 
Glaucoma,  acute,  267 
Glioma  of  brain,  165 
Glossitis,  acute,  292 

Glossopharyngeal  nerve,  functions  of,  152 
Glottis,  edema  of,  322 
Glucose  in  urine,  26 
Gluteal  hernia,  633 
Goitre,  cystic,  320 

lingual,  295 

parenchymatous,  328 

vascular,  of  neck,  315 
Gonococcal  arthritis  of  elbow,  415 
of  hip,  628 
of  knee-joint,  610 

urethritis,  668 
Gonorrhea  in  female,  736 

of  sacro-iliac  joint,  637 
Gonorrheal  arthritis.  134 
of  hand,  366 
of  wrist,  366 

conjunctivitis,  262 

ophthalmia,  262 

osteoperiostitis,  121,  123 

pelvic  peritonitis,  728 

diagnosis  of,  from  appendi- 
citis, 728 

proctitis,  550 

spondylitis,  342 

tenosynovitis,  365 
Gouty  arthritis,  134,  137,  366 

x-rays  in  diagnosis  of,  53 
Graves'  disease,  327 
Groin,  abscess  of,  638 

adenitis  of,  chancroidal,  639 
tuberculous,  639 

inflammations  of,  638 
Gumma  of  abdominal  wall,  488 

of  ankle,  578 

of  brain,  166 

of  breast,  464,  468 

of  bursa,  116 

of  cranial  bones,  234 

of  face.  248 

of  hand,  364 

of  larynx,  324 

of  leg,  582 

of  lips,  280 

of  liver,  495,  519 

of  muscles,  110 

of  nose,  274 

of  palate,  299 

of  parotid  gland,  305 

of  pharynx,  299 


Gumma  of  ribs,  456 
of  scalp,  234 
of  sternum,  456 
of  tendons,  115 
of  tonsils,  297 
Gummatous  adenopathy  of  neck,  316 
osteitis  of  clavicle,  446 

of  humerus,  446 
osteoperiostitis  of  tibia,  588 
ulcers  of  foot,  563 
Gums,  inflammation  of,  291 
Gunshot    injuries  of    thorax,   x-rays    in 

diagnosis  of,  59 
Gynecological   diseases,  constipation  in, 
699 
fever  in,  699 

occurring    after    puberty    and 
during  adolescence,  695 
before  age  of  puberty,  694 
between  ages  of  forty  and 
sixty,  695 
of  twenty-one  and 
forty  in  married 
and  non-virgin- 
al, 695 
of  twenty-one  and 
forty  in  unmar- 
ried    and     vir- 
ginal, 695 
pain  in,  696 

location  of,  696 
symptoms  of,  in  detail,  696 
menstrual,  697 
onset  of,    696 
Gynecomastia,  465 


Hematogenous  nephritis,  acute,  689 
Hallirx  rigidus,  557 

valgus,  557 

varus,  559 
Hammer  finger,  351 

toe,  556 
Hand,  abscess  of,  360 

acute  gouty  periarthritis  of,  366 
post-traumatic  arthritis  of,  366 
rheumatoid  arthritis  of,  366 

angioma  of,  368 

ape,  347 

bones  of,  dislocations  of,  358 
fractures  of,  352 
inflammation  of,  366 

cellulitis  of,  358 

chancre  of,  362 

chronic  traumatic  arthritis  of,  366 

claw,  347 

contractures  of,  346,  348 

cysts  of,  epithelial,  368 

deformities  of,  346 

dermatitis  of,  360 

dislocations  of,  357 

enchondroma  of,  369 

epithelioma  of,  370 

erysipeloid  of,^360 


752 


NDEX 


Hand,  fibrosarcoma  of,  369 

flipper,  348 

furuncle  of,  359 

ganglion  of,  368 

gangrene  of,  365,  366 

gonorrheal  arthritis  of,  366 

gumma  of,  364 

joints  of,  inflammations  of,  366 

keratitis  of,  360 

lipoma  of,  365 

paronychia  of,  359 

psoriasis  of,  360 

pulmonary  osteo-arthropathy  of,  348 

sarcoma  of,  369 

soft  parts  of,  inflammations  of,  358, 
360 

sprains  of,  349 

syphilis  of,  367 

tuberculosis  of,  364 

tumors  of,  368 

ulcers  of,  epitheliomatous,  365 
ayphilitic,  362 
.faumatic,  362 
trophic,  365 
Harelip,  244 
Head,  birth  injuries  of,  227 

foreign  bodies  in,  a;-rays  in  diagnosis 
of,  54 
Heart,  wound  of,  454 
Heberden's  nodes,  137 
Hectic  fever,  73 
Heel,  painful,  561 
Hemangioma  of  face,  251 
Hematemesis,  postoperative,  80 
Hematocele,  657 
Hematoma  of  omentum,  493 

of  vulva,  710 
Hematometra  of  uterus,  726 
Hematosalpinx,  726 
Hematuria,  26 
Hemiplegia,  158 

from  injuries  at  birth,  159 
Hemoglobin,  estimation  of,  17 
Hemoglobinuria,  26 
Hemophilic  arthritis,   136 
Hemorrhage,  78 

intracranial,  227 

of  nose,  271 

of  skin,  93 
Hemorrhoids,  capillary,  551 

internal,  551 

thrombotic  external,  546 

venous,  551 
Hepatic  duct,  stones  in,  522 
Hereditary  syphilis   of    bone,   x-rays  in 

diagnosis  of,  42 
Hermaphrodism,  707 
Hernia,  500 

of  abdominal  wall,  487 

of  bladder,  672 

diaphragmatic,  507 

external,  501 

femoral,  505 

gluteal,  633 

incarcerated,  501 

inguinal,  502 


Hernia,  internal,  501,  507 
irreducible,  501 
ischiatic,  506 
Littre's,  507 
lumbar,  506 
of  muscles,  108 

of  thigh,  615 
obturator,  506,  638 
omental,  500 
perineal,  507 
Richter's,  507 
sciatic,  506 
strangulated,  501 
through  linea  alba,  461 
umbilical,  505 
ventral,  506 
Herpes  of  eyelids,  259 
of  Ups,  279 
of  penis,  643 
vulvae,  709 
Hip,  ankylosis  of,  622 
arthritis  of,  628 

acute  infectious,  628 
gonococcal,  628 
osteomyelitic,  629 
pneumococcal,  629 
rheumatic,   628 
traumatic,  628 
tuberculous,  629 
typhoidal,  628 
contracture  of,  622 
.    contusions  of,  623 
dislocations  of,  626 
congenital,  621 
fractures  of,  624 
malformations  of,  621 
tabetic  arthropathy  of,  632 
trauma  of,  623 
tumors  of,  632 
Hodgkin's  disease,  105,  532 
Hollow  foot,  560 
Hour-glass  stomach,  515 
Humerus,  dislocations  of,  435 
fractures  of,  395 
gummatous  osteitis  of,  446 
,       head  of,  fractures  of,  419 
neck  of,  fractures  of,  422, 423 
osteomyelitis  of,  acute,  440 

chronic,  445 
sarcoma  of,  448 
shaft  of,  fractures  of,  419 
tuberculosis  of,  445 
tuberosities  of,  fractures  of,  422,  424 
tumors  of,  448 
Hydatid  cysts  of  abdominal  wall,  489 
of  breast,  468 
of  spleen,  531 
Hydrocele,  654,  659 

of  round  ligament,  638 
of  spermatic  cord,  638 
Hydrocephalus,  243 
external,  169 
internal,  169 
Hydromyelia,  196 
Hydronephrosis,  496,''689 

x-rays  in  diagnosis  of,  63 


INDEX 


753 


Hydrophobia,  77 
Hydrosalpinx,  729 
Hymen,  imperforate,  707 
Hyoid  bone,  fracture  of,  308 
Hyperemia  of  conjunctiva,  261 
Hypernephroma  of  bone,  130 

of  kidney,  691 
Hyperplasia,  chronic  non-tuberculous  in- 
flammatory, 104 

inflammatory,  of  axillary  glands,  442 
of  neck,  312 

of  omentum,  291 
Hypertrophic   arthritis,  x-rays   in   diag- 
nosis of,  50 

rhinitis,  274 

stenosis  of  pylorus,  512 
Hypertrophy  of  breast,  465 

of  labial  glands,  280 

of  skin,  93 

of  spleen,  530 

of  tonsil,  296 
Hypoglossal  nerve,  functions  of,  153 
Hypospadia,  666,  707 
Hysteria,  traumatic,  212 
Hysterical  joints,  139 
Hysteroneurasthenia,  traumatic,  214 


Idiocy  in  diseases  of  brain,  163 
Ileopsoas  bursitis,  628 
Iliac  abscess,  497 

artery,  aneurysm  of,  497 
Imbecility  in  diseases  of  brain,  163 
Impacted  teeth,  291 
Impaction  of  feces,  539,  552 
Imperforate  hymen,  707 
Impetigo,  92 
Incarcerated  hernia,   501 
Infantile  cervix,  715 
diplegia,  159 
palsy,  194 
paralysis,  159 
uterus,  720 
Infectious  myositis,  108 
Infective  osteomyelitis,  121,  123 

osteoperiostitis,  acute,  121 
Inflamed  skin  tabs,  546 
Inflammations,  68 

acute  suppurative,  of  subdeltoidean 

bursa,  439 
of  arm,  438,  441 
of  auditory  meatus,  255 
of  bladder,  674 
of  bloodvessels,  96 
of  bones,  120,  122 
of  ankle,  575 
of  arm,  445 
of  foot,  575 
of  hand,  366 
of  leg,  587 
of  shoulder,  445 
of  wrist,  366 
'  a;-rays  in  diagnosis  of,  39 
of  breast,  467^1 
48 


Inflammations  of  bursa,  115 
of  shoulder,  442 
of  cervix,  717 
of  chest,  455 
of  conjunctiva,  261 
of  cornea,  266 
of  dural  sinuses,  235 
of  epididymis,  653 
of  esophagus,  472 
of  ethmoid  cells,  277 
of  face,  245 
of  Fallopian  tubes,  727 
of  fibula,  587 
of  fingers,  359 
of  forearm,  382 
of  frontal  sinus,  276 
of  glands  of  neck,  319 
of  groin,  638 
of  gimis,  291 
of  hand,  358,  360 
of  intestines,  485 
of  iris,  267 
of  jaw,  284 
of  joints,  132 

of  ankle,  575 
of  arm,  445 
of  elbow,  414 
of  foot,  575 
of  hand,  366 
of  knee,  610 
of  sacro-iliac,  636 
of  shoulder,  445 
of  wrist,  366 
of  larynx,  323 
of  lips,  279 
of  l5Tnph  glands,  303 
of  maxillary  sinus,  275 
of  mediastinum,  456 
of  middle  ear,  256 
of  mouth,  288 
of  muscles,  108 
of  nasopharynx,  278 
of  neck,  310 
of  nerves  of  arm,  442 
of  shoulder,  442 
of  nose,  273 
of  orbit,  264 
of  ovaries,  727 
of  pancreas,  525 
of  parotid  gland,  302 
of  penis,  641 
periarticular,  606 
of  pericardium,  457 
of  peritoneum,  477 

pelvic,  727 
of  pharynx,  298 
of  pia  arachnoid,  202 
of  popliteal  space,  607 
of  prostate,  662 
of  roots  of  teeth,  290 
of  scalp,  232 
of  seminal  vesicles,  660 
of  shoulder,  438,  441 
of  skin,  84 
of  skull,  232 
of  sphenoidal  sinus,  277 


754 


INDEX 


Inflammations  of  spinal  cord,  198 
of  spine,  340 
of  spleen,  530 
of  stomach,  485 j  515 
of     temporomaxillary     articulation, 

287 
of  tendons,  112 
of  thoracic  duct,  101 
of  thyroid  gland,  327 
of  tibia,  587 
of  tongue,  292 
of  tonsils,  296 
of  ureters,  680 
of  urethra,  667 
of  uterus,  721 
of  vagina,  713 
of  vulva,  707 

of  vulvovaginal  glands,  712 
of  wrist,  358 
Inflammatory    hyperplasia    of    axillary 
glands,  442 
chronic  non-tuberculous,  104 
of  neck,  312 
Influenzal  arthritis,  135 
Infra-orbital  neuralgia,  215 
Infrapatellar  bursitis,  608 
Ingrowing  toenail,  563 
Inguinal  glands,  carcinoma  of,  639 
hernia,  502 

retention  of  testicle,  652 
Insanity  in  diseases  of  brain,  163 
Intercondyloid  fractures,  402 
Intercostal  neuralgia,  222 
Internal  capsule,  145 
Interstitial  keratitis,  267 
Intestines,  actinomycosis  of,  539 
carcinoma  of,  499,  537 
congenital  anomalies  of,  534 
diseases  of,  general  symptomatology 

of,  534 
diverticula  of,  538 
inflammation  of,  485 
lipoma  of,  537 
myoma  of,  537 
obstruction  of,  481 

acute  volvulus,  484 
dynamic  ileus,  481 
intussusception,  484 
mechanical  ileus  without  stran- 
gulation, 482 
obturation  ileus,  481 
strangulation  ileus,  482 
sarcoma  of,  537 
small,  diseases  of,  x-rays  in,  66 
syphilis  of,  536 
tuberculosis  of,  538 
tumors  of,  537 
ulcers  of,  535 
Intra-abdominal  swellings,  490 

of  left  upper  quadrant,  499 
localized,  491 
Intracranial  hemorrhage,  227 
Intraperitoneal  swellings,  492 

of  right  lower  quadrant,  497 
Intussusception,  484,  489 
Inversion  of  testicle,  652 


Inversion  of  uterus,  726 

Iodoform  poisoning,  81 

Iris,  inflammation  of,  267 

Iritis,  267 

Irreducible  hernia,  501 

Ischemic  contracture  of  hand,  348 

Ischiatic  bursitis,  628 

hernia,  506 
Ischiorectal  abscess,  547 
Itch,  90 


Jacksonian  convulsions,  154 
Jaws,  actinomycosis  of,  284 

acute  osteoperiostitis  of,  284 

carcinoma  of,  286 

chondroma  of,  285 

cysts  of,  dentigerous,  285 

epulis  of,  285 

fibroma  of,  285 

fixation  of,  287 

fracture  of,  281 

inflammation  of,  284 

odontoma  of,  285 

osteoma  of,  285 

sarcoma  of,  285 

syphilis  of,  284 

tuberculosis  of,  284 

tumors  of,  285 

a;-rays  in  diagnosis  of,  55 
Joints,  131 

of  ankle,  arthritis  of,  acute,  575,  576 
chronic,  577 
post-travimatic,  577 
tuberculous,  577 
inflammation  of,  575 

of  arm,  inflammation  of,  445 

diseases  of,  x-rays  in  diagnosis  of,  37 

dislocation  of,  131 
congenital,  132 

of  foot,  arthritis  of,  acute,  575 
chronic,  577 
post-traumatic,  577 
tuberculous,  577 
inflammation  of,  575 

free  bodies  in,  138 

of  hand,  inflammations  of,  366 

hysterical,  139 

inflammations  of,  132 

lipoma  of,  139 

loose  bodies  in,  x-rays  in  diagnosis 
of,  53 

metatarsal,  arthritis  of,  576 

metatarsophalangeal,    arthritis   of, 
576 

neurosis  of,  139 

sacro-iliac,  inflammation  of,  636 
strain  of,  635 

of  shoulder,  inflammation  of,  445 

sprains  of,   131 

tarsal,  arthritis  of,  576 

trauma  of,  131 

wounds  of,  131 

of  wrist,  inflammations  of,  366 


INDEX 


755 


Keloid,  94 

Keratitis,  interstitial,  267 
palmar,  3(50 
phl3^ctenular,  267 
vascular,  267 
Keratosis,  95 

of  foot,  562 
Kidneys,  anomalies  of,  683 
calculi  of,  684 
congenitally  misplaced,  497 
contusions  of,  684 
cysts  of,  691 
hypernephroma  of,  691 
movable,  496,  497,  683 
neoplasms  of,  496 
papilloma  of,  691 
suppurative  diseases  of,  687 
syphilis  of,  691 
thrombosis  of,  fever  of,  73 
tuberculosis  of,  690 
tumors  of,  496,  691 

a;-rays  in  diagnosis  of,  63 
Knee,  ankylosis  of,  598 
bursitis  of,  607 
contusions  of,  598 
deformities  of,  597 
fractures  about,  600 
joints  of,  arthritis  of,  acute  rheiuna- 
tic,  610 
traumatic,  609 
chronic  traumatic,  610 
gonococcal,  610 
neuropathic,  613 
syphilitic,  612 
tuberculous,  611 
dislocation  of,  606 
inflammation  of,  609 
neuralgia  of,  613 
tumors  of,  613 
osteoarthritis  of,  599 
sprains  of,  598 
trauma  of,  598 
wounds  of,  598 
Knee-jerk,  156 
Kraurosis  vulvae,  708 
Kyphosis,  336 


Labial  glands,  cysts  of,  281 

hypertrophy  of,  280 
Laboratory  diagnosis,  17 
Lacerations  of  cervix,  716 
Lachrymal  glands,  enlargement  of,  303 
Laryngeal  nerve,  recurrent,  paralysis  of, 

325 
Laryngismus  stridulus,  323 
Laryngitis,  323 

diphtheritic,  323 
Larynx,  burns  of,  323 

carcinoma  of,  325 

contusions  of,  308,  322 

cysts  of,  325 


Larynx,  fibroma  of,  325 

fistula  of,  324 

foreign  bodies  in,  323 

x-rays  in  diagnosis  of,  59 

fracture  of,  308,  322 

gumma  of,  324 

inflammations  of,  323 

lupus  of,  324 

papilloma  of,  325 

sarcoma  of,  325 

scalds  of,  323 

stenosis  of,  324 

syphilis  of,  324 

tuberculosis  of,  324 

tumors  of,   325 
Lateral  curvature  of  spine,  335 

sclerosis,  197 

amyotrophic,  197 
Leg,  bones  of,  fractures  of,  584 
inflammation  of,  587 

cellulitis  of,  583 

contusion  of,  584 

erysipelas  of,  583 

gumma  of,  582 

sarcoma  of,  595 

tumors  of,  595 

ulcers  of,  blastomycotic,  583 
chronic,  582 
syphilitic,  583 
tuberculous,  583 

varicose  veins  of,  580 
Lentigo,  94 

Leptomeningitis,  acute,  235 
Letter  blindness,  144 
Leukemia,  21 

lymphatic,  21,  106,  313 

myelogenous,  21 
Leukemic  enlargement  of  spleen,  531    ' 
Leukocytosis,  18 
Leukoplakia,  293 
Leucorrhea,  699 

mucopurulent,  699 

mucous,  699 

purulent,  699 

putrid,  699 

serous,  699 
Lichen,  93 

Ligamentum  patellae,  rupture  of,  599 
Linea  alba,  hernia  through,  461 
Lingual  goitre,  295 
Lipoma  of  abdominal  wall,  488 

of  arm,  447 

of  axilla,  448 

of  bone,  128 

of  brain,  168 

of  conjunctiva,  263 

of  face,  251 

of  foot,  579 

of  forearm,  384 

of  hand,  365 

of  intestines,  537 

of  joints,  139 

of  lips,  281 

of  muscles,  110 

of  neck,  315,  316,  320 

of  popliteal  space,  613 


756 


INDEX 


Lipoma,  postperitoneal,  492 

of  salivary  glands,  304 

of  scalp,  240 

of  scrotum,  652 

of  shoulder,  448 

of  spermatic  cord,  660 

of  tendons,  115 

of  thigh,  618 

of  thorax,  460 

of  tongue,  295 

of  umbilicus,  489 

of  vulva,  712 
Lips,  adenoma  of,  281 

angioma  of,  280 

chancre  of,  279 

cysts  of,  281 

epithelioma  of,  280 

gumma  of,  280 

herpes  of,  279 

inflammations  of,  279 

lipoma  of,  281 

mucous  patches  of,  279 

tumors  of,  280 
mixed,  281 

ulcerations  of,  279 
Littre's  hernia,  507 
Liver,  abscess  of,  495,  520 

angioma  of,  519 

carcinoma  of,  495,  519 

corset,  518 

cysts  of,  495,  519 

diseases  of,  a:-rays  in,  64 

enlargement  of,  518 

floating,  494 

gumma  of,  495,  519 

lymphangioma  of,  519 

malformations  of,  518 

movable,  518 

sarcoma  of,  519 

spots,  94 

syphilis  of,  519 

transposition  of,  518 

trauma  of,  518 

tuberculosis  of,  519 

tumors  of,  493,  519 
Locomotor  ataxia,  197 
Loose  bodies  in  joints,  x-rays  in  diagnosis 

of,  53 
Lordosis,  336 
Lumbar  hernia,  506 

nerves,  diseases  of,  222 
Lungs,  abscess  of,  459 

x-rays  in  diagnosis  of,  61 

actinomycosis  of,  459 

echinococcus  cysts  of,  459 

gangrene  of,  459 

x-rays  in  diagnosis  of,  61 

sj^philis  of,  459 

tuberculosis  of,  459 

tumor  of,  462  • 

wounds  of,  453 
Lupus  erythematosis,  94 

of  foot,  563 

of  larynx,  324 

vulgaris,  94 

of  vulva,  712 


Luxation.     See  Dislocations. 
Lymph  glands,  actinomycosis  of,  305 
inflammation  of,  303 
sarcoma  of,  303 
tuberculosis  of,  305 
Lymphadenitis,  103 

acute,  246 

tuberculous,  312 
Lymphangiectasis,  102 
Lymphangioma  of  axilla,  448 

of  face,  252 

of  liver,  519 

of  muscles,  110 

of  neck,  102 

of  penis,  647 

of  scrotum,  651 
Lymphangitis,  101 

acute,  101 

chronic,  102 

of  forearm,  382 

malignant,  102 

of  penis,  641 

tuberculous,  102 
Lymphatic  leukemia,  21,  106,  313 
Lymphedema,  103 

of  foot,  562 

of  scrotum,  652 
Lymphoma,  malignant,  of  neck,  313 

of  orbit,  265 
Lymphosarcoma,  106 

of  neck,  313 


M 

Macrocheilia,  102 
Macroglossia,  102 

congenital,  294 
Madura  foot,  563 
Malar  bone,  fracture  of,  245 
Malformations  of  anus,  545 

of  bladder,  671 

of  breast,  464 

of  cervix,  715 

of  ear,  254 

of  elbow,  389 

of  esophagus,  congenital,  472 

of  face,  244 

of  Fallopian  tubes,  726 

of  forearm,  370 

of  hand,  346 

of  hip,  621 

of  liver,  518 

of  neck,  congenital,  306 

of  ovaries,  726 

of  penis,  640 

of  rectum,  545 

of  seminal  vesicles,  660 

of  thorax,  451 

of  tongue,  292 

of  urethra,  666 

of  uterus,  720 

of  vagina,  713 

of  vulva,  707 
Malleolus,  fracture  of,  569 
Malposition  of  bladder,  671 


INDEX 


757 


Mastitis,  467 

syphilitic,  468 
tuberculous,  468 
Mastodynia,  470 
Mastoiditis,  258 

Maxillary  sinus,  carcinoma  of,  276 
enchondroma  of,  276 
fibroma  of,  276 
inflammation  of,  275 
mucous  cysts  of,  276 
myoma  of,  276 
osteoma  of,  276 
sarcoma  of,  276 
tumors  of,  276 
Median  nerve,  paralysis  of,  221 
Mediastinum,  inflammation  of,  456 

tumor  of,  462 
Medulla  oblongata,  147 
tiunors  of,  178 
M^ni^re's  disease,  152 
Meninges  of  brain,  diseases  of,  201 

of  spinal  cord,  diseases  of,  201 
Meningism,  203 
Meningitis,  cerebrospinal,  202 
purulent,  202 
serous,  203,  204 
syphilitic,  166 
tuberculous,  202,  235 
in  infants,  203 
Meningocele,  243,  334 

of  orbit,  266 
Meningomyelocele,  334 
Menorrhagia,  698 

Menstrual  flow,  suppression  of,  698 
Menstruation,  scanty,  698 
Mercurial  poisoning,  81 

stomatitis,   288 
Mesentery,  cysts  of,  493 
Metacarpal  bones,  fracture  of,  353 

tuberculosis  of,  367 
Metatarsal  joints,  arthritis  of,  576 
Metatarsalgia,  anterior,  561 
Metatarsophalangeal  joints,  arthritis  of, 

576 
Metritis,  acute,  722 

chronic,  722 
Metrorrhagia,  698 
Microcephalus,  244 
Mikulicz's  disease,  303 
Miliaria,  91 
Milium  of  eyelids,  260 
MoUuscum  contagiosum,  93 
of  eyelids,  260 
of  scrotum,  650 
Motor  aphasia,  142 

centres  of  brain,  142 

tumors  of,  174 
functions  of  spinal  cord,  191 
Mouth,  epithelioma  of,  289 
inflammations  of,  288 
mucous  patches  of,  288 
Movable  kidney,  496,  497,  683 

liver,  518 
Mucous  patches  of  lips,  279 
of  mouth,  288 
of  tongue,  293 


Mumps,  301 

Muscles,  abdominal,  rupture  of,  488 

angioma  of,  110 

of  arm,  rupture  of,  418 

atrophy  of,  111 

contracture  of.  111 

contusions  of,  107 

echinococcus  cyst  of,  110 

enchondroma  of,  110 

of  eye,  paralysis  of,  268 

of  forearm,  rupture  of,  371 

gumma  of,  110 

hernia  of,  108 

inflammation  of,  108 

lipoma  of,  110 

lymphangioma  of,  110 

neoplasms  of,  110 

paralysis  of,  1 10 

postanesthetic.  111 

rupture  of,  107 

a;-rays  in  diagnosis  of,  67 

sarcoma  of,  110 

syphilis  of,  109 

of  thigh,  hernia  of,  615 
rupture  of,  615 

traumatisms  of,  107 

tuberculosis  of,  109 
Musculospiral  nerve,  paralysis  of,  22  J 
Mycetoma,  563 
Myelitis,  198,  199 
Myelogenous  leukemia,  21 
Myeloma  of  bone,  129 

of  spine,  343 
Myoma  of  intestines,  537 

of  maxillary  sinus,  276 
Myositis,  108 

chronic,  109 

diffuse  phlegmonous,  108 

infectious,  108 

ossifying,  109 

suppurative,  108 

syphilitic,  109 

toxic,  108 

traumatic,  108 

tuberculous,  109 

x-rays  in  diagnosis  of,  66 
Myxedema,   326 
Myxoma  of  bursa,  117 

of  umbilicus,  489 


N 

Nasal  calculi,  273 

duct,  stricture  of,  261 
Nasoliths,  274 

Nasopharyngeal  fibroma,  278 
Nasophar5'nx,  angioma  of,  279 

chondroma  of,  279 

inflammation  of,  278 

tumors  of,  278 
Neck,  actinomycosis  of,  315 

adenopathy  of,  316 

aneurysm  of,  320 

arteriovenous,  321 

carcinoma  of,  314 


758 


INDEX 


Neck,  congenital  malformations  of,  306 

tumors  of,  307 
contusions  of,  308 
cysts  of,  317,  318,  319 
fibroma  of,  317 

glands  of,  inflammation  of,  319 
inflammations  of,  310 
inflammatory  hyperplasia  of,  312 
lipoma  of,  315,  316,  320 
lymphangioma  of,  102 
lymphoma  of,  313 
lymphosarcoma  of,  313 
sarcoma  of,  320 
teratoma  of,  307 
traumatisms  of,  308 
tumors  of,  312 
vascular  goitre  of,  315 
wounds  of,  vascular,  309 
wry-,  218 
Neoplasms  of  kidney,  496 
Nephritis,  acute  hematogenous,  689 
Nephroptosis,  x-rays  in  diagnosis  of,  63 
Nerves,  abducens,  functions  of,  152 

paralysis  of,  152 
auditory,  functions  of,  152 
cervical,  diseases  of,  219 
circumflex,  paralysis  of,  221 
cranial,  diseases  of,  215 
eighth,  functions  of,  152 
eleventh,  functions  of,  153 
external  popliteal,  paralysis  of,  222 
facial,  functions  of,  152 

paralysis  of,  152 
fibroma  of,  222 
fifth,  functions  of,  152 

paralysis  of,  152 
fourth,  paralysis  of,  152 
glossopharyngeal,  functions  of,  152 
hypoglossal,  functions  of,  153 
lumbar,  diseases  of,  222 
median,  paralysis  of,  221 
musculospiral,  paralysis  of,  221 
neuroma  of,  222 
ninth,  functions  of,  152 
oculomotor,  functions  of,  151 
olfactory,  functions  of,  148 
optic,  functions  of,  149 
peripheral,  diseases  of,  214 
pneumogastric,  functions  of,  153 
recurrent  laryngeal,  paralysis  of,  325 
sacral,  diseases  of,  222 
second,  functions  of,  149 
seventh,  functions  of,  152 

paralysis  of,  152 
sixth,  functions  of,  152 

paralysis  of,  152 
spinal  accessory,  functions  of,  153 
tenth,  functions  of,  153 
third,  functions  of,  151 
thoracic,  diseases  of,  222 

paralysis  of,  221 
trigeminus,  functions  of,  152 

paralysis  of,  152 
trochlear,  paralysis  of,  152 
tumors  of,  222 
twelfth,  functions  of,  153 


Nerves,  ulnar,  paralysis  of,  221  ' 

Nervous  system,  diseases  of,  140 
Neuralgia,  brachial,  220 

cervical,  219 

facial,  253 

infra-orbital,  215 

of  knee-joint,  613 

occipital,  219 

supra-orbital,  215 

of  testicle,  658 
Neurasthenia,  traumatic,  211 
Neuritis,  brachial,  219 

optic,  151 
Neurofibroma  of  forearm,  384 

of  scalp,  239 
Neuroma  of  nerves,  222 

of  orbit,  265 

plexiform,  of  eyelids,  260 
Neuropathic  arthritis,  138 
of  elbow,  416 
of  knee-joint,  613 
of  shoulder,  447 
Neurosis  of  joints,  139,  447 

traumatic,  211 
Neurotic  spine,  336 
Nevus,  99 

Ninth  nerve,  functions  of,  152 
Nipple,  chancre  of,  466 

eczema  of,  466 

epithelioma  of,  466 

fissure  of,  466 

Paget's  disease  of,  466 
Noguchi  reaction  in  diagnosis  of  syphilis, 

35 
Noma,  246,  289 
Nose,  acne  rosacea  of,  273 

chancre  of,  273 

congenital  deformities  of,  272 

contusion  of,  272 

diseases  of,  x-rays  in  diagnosis  of,  54 

eczema  of,  273 

elephantiasis  of,  273 

epithelioma  of,  275 

erysipelas  of,  272 

erythema  of,  273 

foreign  bodies  in,  273 

fracture  of,  272 

furuncle  of,  272 

gumma  of,  274 

hemorrhage  of,  271 

inflammation  of,  273 

osteoma  of,  275 

polypi  of,  275 

sarcoma  of,  275 

syphiUs  of,  274 

traumatism  of,  272 

tuberculosis  of,  274 

tumors  of,  275 

ulcerations  of,  273 
Nucleo-albumin  in  urine,  25 


Obstetric  palsy.  111 
Obturation  ileus,  481, 


INDEX 


759 


Obturator  hernia,  506,  638 
Occipital  lobe,  tumors  of,  176 

neuralgia,  219 
Occupation  paresis,  348 

spasm,  348 
Oculomotor  nerve,  functions  of,  151 
Odontoma  of  jaw,  285 
Olecranon,  fractures  of,  405 
Olfactory  nerve,  fimctions  of,  148 
Omental  hernia,  500 
Omentum,  cysts  of,  493 
hematoma  of,  493 
torsion  of,  493 
Operations,  sudden  death  after,  80 
Ophthalmia,  gonorrheal,  262 

neonatorimi,  262 
Ophthalmoplegia,  270 
Optic  nerve,  functions  of,  149 

neuritis,  151 
Orbit,  angioma  of,  264 
carcinoma  of,  265 
contusions  of,  263 
cysts  of,  265,  266 
encephalocele  of,  266 
exostoses  of,  264 
foreign  bodies  in,  .r-rays  in  diagnosis 

of,  54 
fracture  of,  264 
inflammation  of,  264 
lymphoma  of,  265 
meningocele  of,  266 
osteoma  of,  264 
plexiform  neuroma  of,  265 
sarcoma  of,  265 
teratoma  of,  266 
tumors  of,  264,  265 
Os  magnum,  dislocation  of,  358 
Ossifying  myositis,  109 
Osteitis  deformans,  127,  343 

x-rays  in  diagnosis  of,  42 
gummatous,  of  clavicle,  446 

of  humerus,  446 
post-typhoidal,   x-rays  in  diagnosis 

of,  42 
syphilitic,  of  scapula,  446 
tuberculous,  of  scapula,  446 
Osteoarthritis  of  knee,  599 
Osteo-arthropathy  of  hand,  348 
Osteogenesis  imperfecta,  127 
Osteoma  of  bone,  127 
of  brain,  168 
of  jaw,  285 

of  maxillary  sinus,  276 
of  nose,  275 
of  orbit,  264 
of  ribs,  461 
rider's,  109 
of  skuU,  242 
of  sternum,  461 
x-rays  in  diagnosis  of,  45 
Osteomalacia,  126 

Osteomyehtis,  acute,  of  hmnerus,  440 
infective,  121 
of  jaw,  284 
of  ribs,  455 
of  spine,  340 


Osteomyelitis,  acute,  of  sternum,  455 
suppurating,  234 
of  tibia,  588 
x-rays  in  diagnosis  of,  39 
chronic,   125 

of  hiunerus,  445 
infective,  123 
of  ribs,  455 
of  sternum,  455 
traimiatic,  122 
x-rays  in  cUagnosis  of,  39 
of  femur,  shaft,  617 
fever  of,  73 
of  forearm,  383 
of  hip,  629 
of  pelvis,  635 
syphihtic,  124 
of  ribs,  455 
of  sternum,  455 
tuberculous,  123 
of  ribs,  456 
of  sternimi,  456 
typhoidal,  of  ribs,  455 
of  sternum,  455 
Osteoperiostitis,  acute  infective,  121 
of  jaw,  284 
suppurative,  121 
s\-philitic,  121,  123 
traiunatic,  120 
chronic  rheumatic,  123 
gonorrheal,  121,  123 
of  tibia,  acute  traumatic,  587 
gimimatous,  588 
svphilitic,  588 
typhoid,  588 
typhoid,  121 
x-rays  in  diagnosis  of,  56 
Osteosarcoma  of  brain,  164 

x-rays  in  diagnosis  of,  44 
Otitis  media,  acute,  256 

chronic  suppm-ative,  257 
fever  of,  73 
Ovaries,  abscess  of,  727 

cystic  degeneration  of,  731 
cysts  of,  dermoid,  734 
glandular,  732 
papillomatous,  734 
inflammation  of,  727 
malformations  of,  726 
prolapse  of,  731 
rudimentar}-,  726 
timiors  of,  732,  734 


Pachyivieningitis,  cerebral,  201 

spinal,  201 
Paget's  disease  of  bone,  127 

of  nipple,  466 
Painful  foot,  560 

heel,  561 

stiunps,  x-ravs  in  diagnosis  of,  67 
Palate,  abscess  of,  299 

cysts  of,  299 

gumma  of,  299 


760 


INDEX 


Palate,  syphilis  of,  299 

tuberculosis  of,  299 

tumors  of,  299 
Palmar  abscess,  360 

keratitis,  360 
Palsy,  Bell's,  216 

brachial,  220 

crutch.  111 

facial,  216 

infantile,  194 

median  nerve,  221 

musculospiral,  221 

obstetric.  111 

pressure,  79 

reflex.  111 

ulnar  nerve,  221 
Pancreas,  abscess  of,  526 

calculi  of,  527 

carcinoma  of,  527 

cysts  of,  527 

diseases  of,  x-rays  in  diagnosis  of,  64 

inflammation  of,  525 

injuries  of,  525 

tumors  of,  527 
Pancreatitis,  525,  526 
Papilloma  of  anus,  549 

of  esophagus,  474 

of  eyelids,  260 

of  kidney,  691 

of  larynx,  325 

of  penis,  646 
Papillomatous  cysts  of  ovary,  734 
Paralysis  of  abducens  nerve,  152 

of  brachial  plexus,  220 

Brown-Sequard,  200 

of  circumflex  nerves,  221 

in  diseases  of  brain,  155 

Duchenne-Erb,  220 

of  external  popliteal  nerve,  222 

of  facial  nerve,  152 

of  fifth  nerve,  152 

of  fourth  nerve,  152 

of  median  nerve,  221 

of  muscles.  111 
of  eye,  268 

of  musculospiral  nerve,  221 

of  recurrent  laryngeal  nerve,  325 

of  seventh  nerve,  152 

of  sixth  nerve,  152 

of  thoracic  nerves,  221 

of  trigeminus  nerve,  152 

of  trochlear  nerve,  152 

of  ulnar  nerve,  221 
Paraphimosis,  642 
Parasitic  sycosis,  87 
Parathyroid  glands,  326 
Parenchymatous  goitre,  328 
Paresis,  occupation,  348 
Paronychia,  359 
Parotid  gland,  calculus  of,  301 
foreign  bodies  in,  302 
gumma  of,  305 
inflammation  of,  302 
sarcoma  of,  304,  305 
syphilis  of,  302 
tumors  of,  301 


Parotiditis,  302 
Parotitis,  postoperative,  80 
Parovarian  cysts,  734 
Patella,  fracture  of,  600 
Patellar  clonus,  156 

jerk,  156 
Pedicuh,  89 

Pediculosis  of  scrotimi,  650 
Peduncles,  cerebral,  145 
Pelvic  examination,  703 

floor,  relaxation  of,  714 
.  peritonitis,  acute,  727 
chronic,  729 
gonorrheal,  728 

diagnosis   of,  from  appen- 
dicitis, 728 
instrumental,  729 
postoperative,  729 
puerperal,  728 
Pelvis,  foreign  bodies  in,  a:-rays  in  diag- 
nosis, 64 

fractures  of,  635 

osteomyelitis  of,  635 

sarcoma  of,  639 
Penis,  abrasions  of,  643 

abscess  of,  646 

balanoposthitis  of,  642 

cavernitis  of,  641 

cellulitis  of,  641 

chancre  of,  643 

chancroid  of,  645 

congenital  malformations  of,  640 

contusion  of,  640 

cracks  of,  643 

dermatitis  of,  641 

dermoid  cysts  of,  648 

dislocation  of,  640 

eczema  of,  641 

elephantiasis  of,  647 

epithelioma  of,  647 

erysipelas  of,  641 

erythema  intertrigo  of,  641 

fissures  of,  643 

fracture  of,  640 

functional  disturbances  of,  648 

herpes  of,  643 

infiammations  of,  641 

lymphangioma  of,  647 

Ijmiphangitis  of,  641 

papilloma  of,  646 

paraphimosis  of,  642 

phlebitis  of,  641 

pruritus  of,  641 

sarcoma  of,  647 

syphilis  of,  645 

trauma  of,  640 

tuberculosis  of,  646 

tumors  of,  646 

ulcers  of,  646 

urticaria  of,  641 

wounds  of,  640 
Peptones  in  urine,  25 
Perforating  ulcers  of  foot,  563 
Perianal  region,  syphilis  of,  549 
Periarthritis,  acute  gouty,  of  hand,  366 
of  wrist,  366 


INDEX 


761 


Periarticular  inflammation,  606 
Pericarditis,  457 
Pericardium,  adherent,  457 

inflammation  of,  457 
Perichondritis,  323 
Perigastric  adhesions,  513 
Perineal  hernia,  507 
Perinephric  abscess,  497 

x-rays  in  diagnosis  of,  63 

suppuration,  689 
Perineum,  tears  of,  714 
Panosteitis,  acute  suppurative,  x-rays  in 

diagnosis  of,  39 
Peripheral  nerves,  diseases  of,  214 
Perirectal  tumor,  555 
Peritendinous  cellulitis,  112 
Peritoneal  effusion,  diffuse,  490 
Peritoneum,  actinomycosis  of,  480 

carcinoma  of,  481 

inflammation  of,  477 

tuberculosis  of,  480 
Peritonitis,  477 

acute,  478 

chronic,  480 

pelvic,  acute,  727 
chronic,  729 
gonorrheal,  728 

diagnosis  of,  from  appendi- 
citis, 728 
instrumental,  729 
postoperative,  729 
puerperal,  728 

tuberculous,  480 
Peritonsillar  abscess,  296 
Periurethral  abscess,  668 
Pes  planus,  560 
Phagedenic  adenitis,  105 
Phalanges,  tuberculosis  of,  367 
Phantom  tumor,  489 
Pharyngeal  diverticulum,  298 
Pharynx,  foreign  bodies  in,  298 

gumma  of,  299 

inflammation  of,  298 
Phlebitis,   96 

of  penis,  641 

postoperative,  80 
Phlegmonous  myositis,  diffuse,  108 
Phlyctenular  conjunctivitis,  263 

keratitis,  266 
Physometra  of  uterus,  726 
Pia  arachnoid,  inflammation  of,  202 
Pityriasis  rosea,  93 
Plastic  iritis,  267 
Pleura,  tumor  of,  462 
Pleural  effusions,  457 

x-rays  in  diagnosis  of,  62 
Plexiform  neuroma  of  eyelids,  260 

of  orbit,  265 
Pneumocele  of  scalp,  243 
Pneumococci  in  sputum,  32 
Pneumococcic  arthritis,  135,  629 

urethritis,  669 
Pneimiogastric  nerve,  functions  of,  153 
Pneumonia,  postoperative,  80 

x-rays  in  diagnosis  of,  61 
Poisoning,  iodoform,  81 


Poisoning,  mercurial,  81 
Poliomyelitis,  acute  anterior,  194 

chronic,  195 
Polycystic  disease,  497 
Polymastia,  464 
Polyps,  cervical,  717 

of  conjunctiva,  263 

of  ear,  256 

of  esophagus,  475 

of  nose,  275 

of  rectum,  554 

of  tympanum,  257 

urethral,  670 
Polythelia,  464 
Pons,  147 

tumors  of,  178 
Popliteal  artery,  aneurysm  of,  609 

bursitis,  608 

nerve,  external,  paralysis  of,  222 

space,  inflammation  of,  606 
lipoma  of,  613 
Postanesthetic  paralysis  of  muscles.  111 
Posterolateral  sclerosis,  198 
Postoperative  complications  of  celiotomy, 
79 

tetany,  327 

vomiting,  78 
Postperitoneal  lipoma,  492 
Post-traumatic  arthritis,  acute,  of  wrist, 
366 
of  joints  of  ankle,  577 
Post-typhoidal  osteitis,  x-rays  in  diagno- 
sis of,  42 
Pott's  fracture,  568 
Pregnancy,  tubal,  730 
Prepatellar  bursitis,  607,  698 
Pressure  palsies,  79 
Pretibial  bursitis,  607 
Prickly  heat,  91 
Proctitis,  acute  catarrhal,  550 

chronic,  550 

diphtheritic,  550 

dysenteric,  550 

gonorrheal,  550 
Prolapse  of  anus,  551 

of  ovary,  731 

of  uterus,  720 
Prostate,  calculi  of,  663 

x-rays  in  diagnosis  of,  63 

enlargement  of,  663 

inflammation  of,  662 

tumors  of,  664 
Prostatitis,  acute,  662 

chronic,  663 
Pruritus  of  anus,  546 

of  penis,  641 

of  scrotum,  650 

vulvae,  708 
Psammoma  of  brain,  1 68 
Pseudomeningitis,  203 
Psoas  abscess,  497,  615 
Psoriasis,  86,  310 
Psychical  centres  of  brain,  144 

epilepsy,  155 
Pubic  S3maphysis,  disjunction  of,  634 
Puerperal  pelvic  peritonitis,  728 


762 


INDEX 


Pulmonary  osteoarthropathy  of  hand,  348 

Purpura,  93 

Purulent  arthritis  of  infants,  136 

meningitis,  202 
Pyelitis,  687 
Pyelonephritis,  496,  688 
Pyemia,  73 
Pylorus,  hypertrophic  stenosis  of,  512 

obstruction  of,  512 

tumors  of,  493 
Pyometra  of  uterus,  726 
Pyonephrosis,  688 

x-rays  in  diagnosis  of,  63 
Pyorrhea  alveolaris,  291 
Pyosalpinx,  727 
Pyuria,  671 


Quadriceps  tendon,  rupture  of,  599 


R 


Radial  styloid,  dislocation  of,  358 
Radiocarpal  dislocations,  357 
Radio-ulnar  dislocations,  358 
Radius,  dislocations  of,  412 

fractures  of,  380 
head,  405 
lower  extremity,  355 

fissured,  357 
neck,  405 

sublirsation  of,  413 
Ranula,  295 
Raynaud's  disease,  365 
Recklinghausen's  disease,  222 
Rectal  centres  of  spinal  cord,  193 
Rectocele,  715 

Rectovaginal  fistula,  714,  735 
Rectum,  carcinoma  of,  555 

congenital  malformations  of,  545 

foreign  bodies  in,  552 

polyp  of,  554 

sarcoma  of,  555 

stricture  of,  553,  554 

trauma  of,  552 

tumors  of,  554 

ulcers  of,  552,  553 
Reflex  palsies,  112 
Reflexes,  155 

abdominal,  157 

Babinski's,  157 

biceps,  156 

cremasteric,  157 

plantar,  157 

skin,  157 

superficial,  157 

triceps,  156 

umbilical,  157 
Renal  artery,  aneurysm  of,  691 

calculi,  684 

a;-ra_ys  in  diagnosis  of,  62 

hematuria,  26 

tumors,  496 


Reproductive  organs,  anatomy  of,  693 
examination  of,  700 

abdominal,  position  for,  702 
armamentarium  for,  703 
position  of  patient  in,  701 
preparation  of  patient  for, 
702 
Retention  of  testicle,  abdominal,  651 
cruroscrotal,  651 
inguinal,  651 
Retrocalcaneal  bursitis,  574 
Retroperitoneal  cysts,  492 

swellings,  491 
Retropharyngeal  abscess,  298 
Retroposition  of  uterus,  720 
Rheumatic  arthritis,  134 
of  elbow,  415 
of  hip,  628 
of  knee-joint,  610 
of    temporomaxillary    articula- 
tion, 287 
osteoperiostitis,  123 
Rheumatism  of  sacro-iliac  joint,  636 
Rheumatoid  arthritis,  343,  366 
Rhinitis,  acute,  273 
atrophic,  274 
chronic,  274 
diphtheritic,  273 
hypertrophic,  274 
Ribs,  cervical,  308,  335 

x-rays  in  diagnosis  of,  54 
chondroma  of,  461 
deformities  of,  x-rays  in  diagnosis  of, 

57 
fracture  of,  454 

x-rays  in  diagnosis  of,  56 
gumma  of,  456 
osteoma  of,  461 
osteomyelitis  of,  455,  456 
sarcoma  of,  461 
tumors  of,  461 

x-rays  in  diagnosis  of,  57 
Richter's  hernia,  507 
Rickets,  126 

x-rays  in  diagnosis  of,  43 
Rider's  osteoma,  109 
Riedel's  lobe,  494 
Ringworm,  87 

Round  ligament,  hydrocele  of,  638 
Rudimentary  ovary,  726 
Rupture  of  bladder,  674 
of  bloodvessels,  96 
of  crucial  ligaments,  599 
of  esophagus,  472 
of  ligamentum  patellae,  599 
of  muscles,  107 

of  abdomen,  488 
of  arm,  418 
of  forearm,  371 
of  thigh,  615 
x-rays  in  diagnosis  of,  67 
of  quadriceps  tendon,  599  , 
of  semilunar  cartilage,  599 
of  spleen,  530 
of  stomach,  510 
of  tendons,  112 


INDEX 


763 


Rupture  of  tendons  of  foot,  574 
of  forearm,  371 
of  thoracic  duct,  101 
of  ureter,  680 
of  urethra,  traumatic,  666 


Sacral  nerves,  diseases  of,  222 
Sacrococcj'^geal  tmnors,  congenital,  633 
Sacro-iliac  joint,  chondroma  of,  637 

exostoses  of,  637 

gonorrhea  of,  637 

inflammation  of,  636 

rheumatism  of,  637 

sarcoma  of,  637 

strain  of,  635 

syphilis  of,  637 

tuberculosis  of,  636 

tumors  of,  637 
Sacrum,  cysts  of,  334 

tumors  of,  334 
Salivary  calculi,  291 

x-rays  in  diagnosis  of,  55 
glands,  carcinoma  of,  305 

chondroma  of,  304 

cysts  of,  304 

diseases  of,  300 

enlargement  of,  303 

fibroma  of,  304 

fistula  of,  305 

lipoma  of,  304 

tumors  of,  304 
Salpingitis,  acute,  727 

chronic,  729 
Sarcoma  of  abdominal  wall,  489 
of  arm,  447 
of  axilla,  448 
of  bone,  129 

x-rays  in  diagnosis  of,  41,  43 
of  brain,  164 
of  bursa,  117 
of  buttocks,  633 
of  cervix,  719 
of  eyelids,  260 
of  face,  252 
of  foot,  563,  579 
of  forearm,  384 
of  hand,  369 
of  humerus,  448 
of  intestines,  537 
of  jaw,  285 
of  larynx,  325 
of  liver,  519 
of  lymph  glands,  303 
of  maxillary  sinus,  276 
of  muscles,  110 
of  neck,  320 
of  nose,  275 
of  orbit,  265 

of  parotid  gland,  304,  305 
of  pelvis,  639 
of  penis,  647 
of  rectum,  555 
of  ribs,  461 


Sarcoma  of  sacro-iliac  joint,  637 

of  scalp,  242 

of  skin,  95 

of  skull,  242 

of  spinal  cord,  206 

of  spine,  343 

of  spleen,  499,  531 

of  sternum,  461 

of  thigh,  618 

of  thorax,  460 

of  thymus  gland,  331 

of  thyroid  gland,  329 

of  tibia,  595,  614 

of  tongue,  295 

of  tonsils,  297 

of  imabilicus,  489 

of  uterus,  723 

of  vagina,  714 

of  vulva,  712 
Scalds  of  larynx,  323 
Scalp,  aneurysm  of,  238,  239 

angioma  of,  238 

carcinoma  of,  241 

contusions  of,  223 

cysts  of,  sebaceous,  240 

elephantiasis  of,  239 

epithelioma  of,  241 

erysipelas  of,  233 

fibroljonphangioma  of,  239 

fibroma  of,  239 

furuncles  of,  233 

gumma  of,  234 

inflammations  of,  232 

lipoma  of,  240 

neurofibroma  of,  239 

pneumocele  of,  243 

sarcoma  of,  242 

seborrhea  of,  232 

syphilis  of,  233 

tuberculosis  of,  233 

tumors  of,  238 

verruca  of,  238 

warts  of,  238 

wens  of,  240 
Scaphoid,  tarsal,  fracture  of,  565 
Scapula,  fractures  of,  430 

acromion  process,  433 
coracoid  process,  433 
neck  of,  433 

syphilitic  osteitis  of,  446 

tuberculous  osteitis  of,  446 
Scarlet  fever  arthritis,  135 
Sciatic  hernia,  506 
Sciatica,  222,  616 
Sclerosing  gastritis,  515 
Sclerosis  of  internal  vesical  sphincter,  664 

lateral,  197 

amyotrophic,  197 

posterolateral,  198 
Scoliosis,  x-rays  in  diagnosis  of,  54,  58 
Scrotum,  abscess  of,  650 

cellulitis  of,  651 

contusions  of,  649 

eczema  of,  649 

edema  of,  649 

emphysema  of,  649 


764 


INDEX 


Scrotum,  epithelioma  of,  651 
erosions  of,  649 
erythema  intertrigo  of,  649 
lipoma  of,  651 
lymphangioma  of,  651 
lymphedema  of,  651 
molluscum  contagiosum  of,  650 
pediculosis  of,  650 
pruritus  of,  650 
sebaceous  cysts  of,  650 
tumors  of,  651 
ulcers  of,  649 
Sebaceous  cysts  of  breast,  468 
of  face,  252 
of  neck,  319 
of  scalp,  240 
of  scrotum,  650 
Seborrhea,  91 

of  scalp,  232 
Second  nerve,  functions  of,  149 
Secretions,  examination  of,  34,  35 
Semilunar  bone,  dislocation  of,  358 
cartilage,  rupture  of,  599 
subluxation  of,  598 
Seminal  vesicles,  cysts  of,  661 
inflammation  of,  660 
malformations  of,  660 
malignant  infiltration  of,  662 
Senile  gangrene,  100 

of  hand,  365 
Sensory  aphasia,  144 
centres  of  brain,  142 

timiors  of,  175 
functions  of  spinal  cord,  193 
Septicemia,  70 
Serous  meningitis,  203,  204 
Seventh  nerve,  functions  of,  152 

paralysis  of,  152 
Sexual  centres  of  spinal  cord,  193 
Shock,  78 

Shoulder,  arthritis  of,  acute  serous,  -440 
suppurative,  440 
chronic,  446 
fungous,  447 
neuropathic,  447 
serofibrinous,  440 
tuberculous,  447 
bones  of,  inflammations  of,  445 
bursa  of,  inflammation  of,  442 
contusions  of,  418 
inflammations  of,  438,  441 
joints  of,  dislocations  of,  435 
inflammations  of,  445 
neuroses  of,  447 
a;-rays  in  diagnosis  of,  47 
lipoma  of,  448 

nerves  of,  inflammation  of,  442 
sprains  of,  418 
traumatisms  of,  418 
tumors  of,  447 
Sigmoid,  diseases  of,  x-rays  in,  66 
Sixth  nerve,  functions  of,  152 

paralysis  of,  152 
Skin,  epithelioma  of,  95 

erythematous  lesions  of,  91 
hemorrhages  of,  93 


Skin,  hypertrophies  of,  93 
inflammations  of,  84 
lesions  of  face,  245 
sarcoma  of,  95 
syphilitic  lesions  of,  85 
tabs,  307 

inflamed,  546 
tuberculosis  of,  94 
Skull,  anterior  fossa  of,  fracture  of,  228 
chondroma  of,  242 
cysts  of,  dermoid,  243 
fracture  of  base  of,  186,  223 
inflammations  of,  232 
middle  fossa  of,  fracture  of,  229 
osteoma  of,  242 

posterior  fossa  of,  fracture  of,  230 
sarcoma  of,  242 
tumors  of,  238 

x-rays  in  diagnosis  of,  55 
wounds  of,  231 
gunshot,  232 
penetrating,  231 
Spasm,  facial,  216 

occupation,  348 
Spermatic  cord,  hydrocele  of,  638 

lipoma  of,  660 
Sphenoidal  sinus,  inflammation  of,  277 
Spina  bifida,  211,  334 
occulta,  334 
ventosa,  367 
Spinal  accessory  nerve,  function  of,  153 
coliunn,  332.     See  also  Vertebra  and 
spine, 
arthritis  of,  x-rays  in  diagnosis 

of,  58 
anomalies  of,  334 
general  s5Tnptomatology  of  af- 
fection of,  333 
cord,  anatomical  relations  of,  187 
anterior  horn  of,  diseases  of,  194 
centres  of,  bladder,  193 
rectal,  193 
sexual,  193 
cysts  of,  206 
fibroma  of,  206 
functions  of,  190 
motor,  191 
sensory,  193 
inflammation  of,  198 
injuries  of,  207,  208 
lateral  columns  of,  diseases  of, 

197 
localization  of,  190 
meninges  of,  diseases  of,  201 
motor  columns  of,  diseases  of, 

197  _ 
posterior  columns  of,  diseases  of, 

197 
roots  of,  188 

anterior,  lesions  of,  200 
posterior,  lesions  of,  200 
sarcoma  of,  206 
segments  of,  190 
tumors  of,  205 
unilateral  lesions  of,  200 
fluid,  examination  of,  35 


INDEX 


765 


Spinal  pachymeningitis,  201 
Spine,  actinomycosis  of,  343 

acute  osteomyelitis  of,  340 

carcinoma  of,  343 

contusions  of,  336 

curvature  of,  335 

dislocations  of,  336 

imaccompanied  by  fracture,  338 

exostoses  of,  343 

fracture  dislocations  of,  339 

fractures  of,  336 

unaccompanied  by  dislocation, 
339 

inflammation  of,  340 

lumbar,  diseases  of,  x-rays  in  diag- 
nosis of,  65 

myeloma  of,  343 

neurotic,  336 

sarcoma  of,  343 

sprain  of,  336 

syphilis  of,  343 

trauma  of,  336 

tuberculosis  of,  340 

tumors  of,  343 

typhoid,  342 

wounds  of,  340 
Spirocheta  pallida,  36 
Spleen,  abscess  of,  499 

acute  suppurative  infection  of,  530 

anomalies  of,  529 

carcinoma  of,  531 

congestion  of,  530 

cysts  of,  531 

degeneration  of,  531 

diseases  of,  x-rays  in  diagnosis  of,  64 

enlargement  of,  499 

floating,  499 

hypertrophy  of,  530 

inflammations  of,  530 

leukemic  enlargement  of,  531 

rupture  of,  530 

sarcoma  of,  499,  531 

syphilis  of,  531 

traumatism  of,  530 

tuberculosis  of,  531 

tumors  of,  531 

wounds  of,  530 
Splenic  anemia,  531 
Splenitis,  530 
Spondylitis,  acute  suppurative,  340 

chronic  traumatic,  342 

deformans,  343 

gonorrheal,  342 

syphilitic,   343 

tuberculous,  340 

t3^phoidal,  342 
Sprains  of  ankle,  564 

of  elbow,  393 

of  foot,  564 

of  joints,  131 

of  knee,  598 

of  shoulder,  418 

of  spine,  336 

of     temporomaxillarv    articulation, 
287 

of  vertebra,  207 


Sputum,  examination  of,  31 

pneumococcus  in,  32 

tubercle  bacilli  in,  32 
Stenosis  of  larynx,  324 

of  pylorus,  hypertrophic,  512 

of  trachea,  324 
Sterility,  700 

developmental,  700 

functional,  700 

inflammatory  diseases  and,  700 

mechanical  impediments  and,  700 
Sternum,  chondroma  of,  461 

diseases  of,  x-rays  in  diagnosis  of,  57 

dislocation  of,  x-rays  in  diagnosis  of, 
57 

fracture  of,  454 

x-rays  in  diagnosis  of,  57 

gumma  of,  456 

osteoma  of,  461 

osteomyelitis  of,  455,  456 

tumors  of,  461 

x-rays  in  diagnosis  of,  57 
Still's  disease,  135 
Stomach,  abscess  of,  493 

carcinoma  of,  514 

contusions  of,  510 

dilatation  of,  acute,  511 

diseases  of,  x-rays  in  diagnosis  of,  65 

foreign  bodies  in,  511 

hourglass,  515 

inflammations  of,  485,  515 

rupture  of,  510 

trauma  of,  51.0 

tumors  of,  493,  514 

ulcer  of,  513 

volvulus  of,  513 

wounds  of,  51 1 
Stomatitis,  288 

gangrenous,  289 

mercurial,  288 

ulceromembranous,  289 
Strain  of  sacro-ihac  joint,  635 
Strangulated  hernia,  501 
Strangulation  ileus,  482 
Stricture  of  esophagus,  474 

of  nasal  duct,  261 

of  rectum,  553,  554 

of  ureter,  680 
Stye,  259 

Subastragaloid  dislocations,  571 
Subclavian  artery,  aneurysm  of,  321 
Subcoracoid  bursitis,  442 
Subcortical  centres  of  brain,  145 

tumors  of,  178 
Subdeltoidean    bursa,    inflammation    of, 
acute  suppurative,  439 

bursitis,  442 
Subhyoid  biu-sa,  319 
Sublingual  abscess,  310 

gland,  diseases  of,  301 
Subluxation  of  radius,  413 

of  semilunar  cartilage,  598 

of  wrist,  358 
Submammary  abscess,  466 
Submaxillary  adenitis,  310 

gland,  diseases  of,  300 


766 


INDEX 


Submaxillary  gland,  foreign   bodies    in, 
306 
tumors  of,  306 
Submental  adenitis,  310 
Subphrenic  abscess,  495,  499 

a;-rays  in  diagnosis  of,  62 
Suburethral  abscess,  736 
Suppuration,  perinephric,  689 
Suppurative  arthritis  of  elbow,  415 

catarrhal  pancreatitis,  526 

disease  of  kidney,  687 

myositis,  108 

osteoperiostitis,  121 
Supracondyloid  fracture,  396 
Suprahyoid  bursa,  319 
Supramalleolar  fractures,  569 
Supramammary  abscess,  466 
Supra-orbital  neuralgia,  215 
Suprarenal  bodies,  tumors  of,  497 

gland,  cysts  of,  692 
tumors  of,  692 

tumors,  496 
Sycosis,  92 

parasitic,  87 
Symmetrical  gangrene  of  hand,  365 
Synovitis,  fungous,  114 
Syphilis  of  abdominal  wall,  488 

of  arms,  549 

of  biceps  muscle,  441 

of  bones,  121,  123,  124 

hereditary,   x-rays  in  diagnosis 

of,  42 
x-rays  in  diagnosis  of,  40 

of  brain,  166 

of  breast,  468 

of  bursa,  116 

of  esophagus,  474 

of  face,  248 

of  forearm,  383 

of  hand,  362,  367 

of  intestines,  536 

of  jaw,  284 

of  joints,  138 

of  kidneys,  691 

of  larynx,  324 

of  liver,  519 

of  lung,  459 

of  muscles,  109 

Noguchi  reaction  in,  35 

of  nose,  274 

of  palate,  299 

of  parotid  gland,  302 

of  penis,  645 

of  perianal  region,  549 

of  sacro-iliac  joint,  637 

of  scalp,  233 

of  spine,  343 

of  spleen,  531 

of  tendons,  112 

of  testicle,  658 

of  tongue,  293 

of  tonsils,  297 

of  vertebraj,  343 

of  vulva,  709 

Wasserman  reaction  in,  35 
Syphilitic  adenitis,  104 


Syphilitic  adenopathy  of  neck,  316 

arthritis  of  elbow,  415 
of  knee-joint,  612 

dactylitis,  x-rays  in  diagnosis  of,  42 

lesions  of  skin,  85 

meningitis,  166 

osteitis  of  scapula,  446 

osteomyelitis  of  ribs,  455 
of  sternum,  455 

osteoperiostitis  of  tibia,  588 

stricture  of  rectum,  554 

ulcers  of  leg,  583 
of  rectum,  553 

urethritis,  669 
Syringomyelia,  196 
Syringomyelic  arthropathy,  138 


Tabes  dorsalis,  197 

Tabetic  arthropathy,  138,  579,  632 

Tarsal  joints,  arthritis  of,  576 

scaphoid,  fracture  of,  565 
Tarsus,  dislocations  of,  x-rays  in  diagnosis 

of,  49 
Teeth,  caries  of,  289 

cementum  of,  hyperplasia  of,  291 

impacted,  291 

roots  of,  abscess  of,  290 
inflammation  of,  290 
Telangiectasis,  99 
Temporal  lobe,  tumors  of,  177 
Temporomaxillary  articulation,  286 
arthritis  of,  287 
luxation  of,  287 
sprains  of,  287 
Tendons,  fibroma  of,  115 

fibrosarcoma  of,  115 

of  foot,  dislocations  of,  572 
rupture  of,  574 

of  forearm,  rupture  of,  371 

inflammation  of,  112 

lipoma  of,  115 

luxation  of,  112 

rupture  of,  112 

sjrphilis  of,  112 

trauma  of,  112 

tumors  of,  115 

wounds  of,  112 
Tenosynovitis,  112,  574 

acute,  371 

gonorrheal,  365 

gummatous,  115 

syphilitic,  114 

tuberculous,  364 
Tenth  nerve,  functions  of,  153 
Teratoma  of  neck,  307 

of  orbit,  266 
Testicle,  congenital  anomalies  of,  651 

contusion  of,  653 

cysts  of,  656 

dislocation  of,  653 

inversion  of,  652 

neuralgia  of,  658 

retention  of,  651 


INDEX 


767 


Testicle,  syphilis  of,  658 
torsion  of,  652 
tiunors  of,  658 
undescended,  638 
Tetanus,  76 

Tetany,  postoperative,  327 
Thigh,  carcinoma  of,  618 
contusions  of,  615 
cysts  of,  619 
inflammations  of,  617 
lipoma  of,  618 
muscles  of,  hernia  of,  615 

rupture  of,  615 
sarcoma  of,  618 
tumors  of,  618 
Third  nerve,  functions  of,  151 
Thoracic  duct,  inflammation  of,  101 
rupture  of,  101 
wounds  of,  101 
nerves,  diseases  of,  222 
paralysis  of,  221 
Thorax,  abscess  of,  452 
carcinoma  of,  460 
cellulitis  of,  451 
concussion  of,  453 
congenital  malformations  of,  451 
contusion  of,  453 
epithelioma  of,  461 
fibroma  of.  460 

gunshot  injuries  of,  rc-rays  in  diag- 
nosis of,  59 
inflammations  of,  455 
lipoma  of,  460 
sarcoma  of,  460 
traumatism  of,  453 
tumors  of,  460 
wounds  of,  453 
Thrombosis,  96 

of  kidney,  fever  of,  73 
Thrombotic  external  hemorrhoids,  546 
Thrush,  288 
Thymus  death,  331 

gland,  diseases  of,  331 
Thyroid  gland,  carcinoma  of,  330 
congestion  of,  327 
echinococcus  cysts  of,  331 
inflammation  of,  327 
sarcoma  of,  329 
scirrhus  of,  331 
tumors  of,  328 
Thyroiditis,  acute,  327 
Tibia,  abscess  of,  591 
dislocation  of,  606 
exostoses  of,  613 
fracture  of,  584,  604 
inflammation  of,  587 
osteomj-elitis  of,  588 
osteoperiostitis  of,  587,  588 
sarcoma  of,  595,  614 
tubercles  of,  separation  of,  605 
tuberculosis  of,  592 
Tibiotarsal  dislocation,  572 
Tic  douloureux,  215 

facial,  216 
Tinea  of  axilla,  438 
circinata,  87 


Tinea  cruris,  88 

favosa,  86 

tonsurans,   87 

versicolor,  89 
Toe,  hammer,  556 

nail,  ingrowing,  563 
Tongue,  actinomycosis  of,  294 

angioma  of,  294 

cancer  of,  294 

chancre  of,  293 

cysts  of,  295,  296 

fibroma  of,  295 

inflammation  of,  292 

lipoma  of,  295 

malformations  of,  292 

mucous  patches  of,  293 

sarcoma  of,  295 

syphilis  of,  293 

tuberculosis  of,  293 

tumors  of,  294 

ulcers  of,  292 
Tongue-tie,  292 
Tonsillitis,  acute,  296 

diphtheritic,  297 

follicular,  fever  of,  73 

ulceromembranous,  297 
Tonsils,  abscess  of,  296 

carcinoma  of,  298 

gumma  of,  297 

chancre  of,  297 

hypertrophy  of,  296 
inflammation  of,  296 
sarcoma  of,  297 
syphihs  of,  297 
tuberculosis  of,  297 
tumors  of,  297 
Torsion  of  omentum,  493 

of  testicle,  652 
TorticoUis,  218 
acquired,  309 
congenital,  307 
Toxic  myositis,  108 
Trachea,  foreign  bodies  in,  323 

x-rays  in  diagnosis  of,  59 
stenosis  of,  324 
Trachoma,  263 

Transudates,  examination  of,  34 
Trauma  of  ankle,  564 
of  arm,  418 
of  bladder,  673 
of  bloodvessels,  96 
of  bones,  118 

complications  and  sequels  of,  78 
of  elbow,  390 
of  foot,  564 
of  forearm,  371 
of  hip,  623 
of  joints,  131 
of  knee,  598 
of  liver,  518 
of  muscles,  107 
of  neck,  308 
of  nose,  272 
of  penis,  640 
of  rectum,  552 
of  shoulder,  418 


768 


INDEX 


Trauma  of  spine,  336 

of  spleen,  530 

of  stomach,  510 

of  tendons,  112 

of  thorax,  453 
Traumatic    aneurj^sms,   x-rays   in   diag- 
nosis of,  66 

arthritis,  133,  136 
of  elbow,  414 
of  hand, 366 
of  hip,  628 

of  knee-joint,  609,  610 
of  wrist,  366 

aseptic  fever,  69 

dislocation  of  hip,   a;-rays  in  diag- 
nosis of,  47 

encephalohj^drocele,  230 

gangrene,  99,  365 

hysteria,  212 

hj'stero-neurasthenia,  214 

myositis,  108 

neurasthenia,  211 

neuroses,  211 

osteomj^elitis,  122 

osteoperiostitis,  acute,  120 
of  tibia,  587 

mixture  of  urethra,  666 

spondylitis,  chronic,  342 

ulcer  of  hand,  362 

urethritis,  668 
Triceps  clonus,  156 

reflex,  156 
Trigeminus  nerve,  functions  of,  152 
Trigger-finger,  348 
Trochanteric  bursitis,  628 
Trochlear  nerve,  functions  of,  152 
Trophic  ulcers  of  hand,  365 
Tubal  pregnancy,  730 
Tubercle  bacilli  in  sputum,  32 
Tuberculous  meningitis,  202,  225 

in  infants,  203 
Tuberculosis  of  adrenal  gland,  692 

of  arms,  549 

of  bladder,  678 

of  bone,  123 

.T-raj^s  in  diagnosis  of,  39 

of  brain,  165 

of  breast,  464,  468 

of  bursa,  116 

of  cecimi,  498 

of  epididjonis,  657 

of  esophagus,  474 

of  evelids,  259 

of  face,  247 

of  fibula,  592 

of  forearm,  384 

of  hand,  364 

of  hip,  629 

of  hmnerus,  445 

of  intestines,  538 

of  jaw,  284 

of  joints,  135,  137 

of  kidneys,  690 

of  larynx,  324 

of  liver,  519 

of  lungs,  459 


Tuberculosis  of  Ijnnph  glands,  305 
of  metacarpal  bones,  367 
of  muscles,  109 
of  nose,  274 
of  palate,  299 
of  penis,  646 
of  peritoneum,  480 
of  phalanges,  367 
of  sacro-iliac  joint,  636 
of  scalp,  233 
of  seminal  vesicles,  661 
of  skin,  94 
of  spine,  340 
of  spleen,  531    ■ 
of  tendons,  113 
of  tibia,  592 
of  tongue,  293 
of  tonsils,  297 
of  ureter,  682 
of  uterus,  726 
of  wrist,  367 
Tuberculous  adenitis,  105 

of  axillary  glands,  442 

of  groin,  639 
arthritis  of  elbow,  415 

of  joints  of  ankle,  577 

of  knee-joint,  611 

of  shoulder,  447 

of    temporomaxillary    articula- 
tion, 287 

x-raj^s  in  diagnosis  of,  49 
fistula  of  anus,  548 
infection,  75 
lymphadenitis,  312 
lymphangitis,  102 
osteitis  of  scapula,  446 
osteomj^elitis  of  ribs,  456 

of  sternimi,  456 
prepatellar  bursitis,  607 
sinus,  247 

stricture  of  rectum,  554 
tenosynovitis,  364 
ulcers  of  leg,  583 

of  rectmn,  553 
urethritis,  670 
Timiors,  82 

of  abdomen,  486 

x-raj^s  in  diagnosis  of,  65 
of  anus,  550 
of  arm,  447,  519 
of  auricle,  254 
of  bladder,  494,  678 
of  bloodvessels,  99 
of  bone,  127 

x-raj^s  in  diagnosis  of,  43 
of  brain,  163 

x-rays  in  diagnosis  of,  55 
of  breast,  464,  468 
of  bursa,  117 
carotid,  306 
of  Cauda  equina,  206 
of  cerebellum,  179 
of  cervix,  717 
of  coccyx,  334 
of  conjunctiva,  263 
of  crus,  178 


INDEX 


7G9 


Tumors  of  ear,  256 
of  face,  250 
of  forearm,  384 
of  foot,  579 
of  frontal  lobe,  171 

sinus,  277 
of  gall-bladder,  496 
of  hand,  368 
of  intestines,  357 
of  jaw,  285 

x-rays  in  diagnosis  of,  55 
of  joints,  139 
of  kidney,  496,  691 

x-rays  in  diagnosis,  63 
of  knee-joint,  613 
of  larynx,  325 
of  leg,  595 
of  lips,  280 
of  liver,  493,  519 
of  lung,  462 
of  maxillary  sinus,  276 
of  mediastinum,  462 
of  medulla  oblongata,  178 
of  motor  area  of  brain,  174 
of  mouth,  289 
of  muscles,  110 
of  nasopharynx,  278 
of  neck,  312 

congenital,  307 
of  nerves,  222 
of  nose,  275 
of  occipital  lobe,  176 
of  orbit,  264 
of  ovary,   732,   734 
of  palate,  299 
of  pancreas,  527 
of  parotid  glands,  301 
of  penis,  646 
perirectal,  555 
phantom,   489 
of  pleura,  462 
of  pons,  178 
of  prostate,  664 
of  pylorus,  493 
of  rectum,  554 
of  ribs,  461 

x-rays  in  diagnosis  of,  57 
sacrococcygeal,  congenital,  633 
of  sacro-iiiac  joint,  637 
of  sacrum,  334 
of  salivary  glands,  304 
of  scalp,  238 
of  scrotum,  651 
of  sensory  area  of  brain,  175 
of  shoulder,  447 
of  skull,  238 

x-rays  in  diagnosis  of,  55 
of  spinal  cord,  205 
of  spine,  343 
of  spleen,  531 
of  sternum,  461 

x-rays  in  diagnosis  of,  57 
of  stomach,  493,  514 
of  subcortical  area  of  brain,  178 
of  submaxillary  gland,  306 
suprarenal,  496,  497 
49 


Tumors  of  suprarenal  gland,  692 

of  temporal  lobe,  177 

of  tendons,  115 

of  testicle,  658 

of  thigh,  617 

of  thorax,  460 

of  thyroid  gland,  328 

of  tongue,  294 

of  tonsils,  297 

of  umbilicus,  489 

of  uterus,  722 

of  vagina,  714 

of  vertebra?,  206,  343  _ 

x-rays  in  diagnosis  of,  57 

of  visual  area  of  brain,  176 

of  vulva,  709 

of  wrist,  368 
Twelfth  nerve,  functions  of,  153 
Tj^mpanites,  490 
Tympanum,  cancer  of,  257 

congestion  of,  255 

polypi  of,  257 

wounds  of,  254 
Typhoidal  arthritis,  135,  628 

osteomyelitis  of  ribs,  455 
of  sternum,  455 

osteoperiostitis,  121,  588 

spondylitis,  342 


Ulcer  of  cornea,  266 

of  duodenimi,  515 

of  esophagus,  474 

of  foot,  563 

of  hand,  362,  365 

of  intestines,  535 

of  leg,  582,  583 

of  lips,  279 

of  nose,  273 

of  penis,  646 

of  rectum,  552,  553 

of  stomach,  513 

of  tongue,  292 
Ulna,  dislocations  of,  412 

fractures  of,  380 

coronoid  process  of,  405 
Ulnar  nerve,  paralysis  of,  221 

styloid,  dislocation  of,  358 
fracture  of,  357 
Umbilical  hernia,  505 
Umbilicus,  abscess  of,  490 

carcinoma  of,  489 

congenital  anomalies  of,  489 

eczema  of,  490 

gumma  of,  489 

lipoma  of,  489 

myxoma  of,  489 

sarcoma  of,  489 

tumors  of,  489 
Undescended  testicle,  638 
Urachus,  cyst  of,  489 
Ureters,  anomalies  of,  679 

calculi  of,  680 

carcinoma  of,  682 


770 


INDEX 


Ureters,  fistula  of,  681 

inflammation  of,  680 

rupture  of,  679 

stricture  of,  680 

tuberculosis  of,  682 

wound  of,  680 
Urethra,  abscess  of,  668 

atresia  of,  707 

foreign  bodies  in,  667 

inflammation  of,  667 

malformations  of,  666 

polyps  of,  670 

rupture  of,  traumatic,  666 
Urethral  caruncle,  735 

epididymitis,  654 
Urethritis,  667,  735 

acute  traumatic,  668 

chancroidal,  669 

chronic,  669 

diphtheritic,  669 

eruptive,  668 

gonococcic,  668 

infectious,  668 

pneumococcic,  669 

syphilitic,   669 

tuberculous,  670 
Urine,  acetone  in,  26 

albumin  in,  24 

bacteriology  of,  27 

Bence-Jones  body  in,  25 

bile  pigment  in,  27 

blood  in,  26 

/?-oxybutyric  acid  in,  26 

diacetic  acid  in,  26 

examination  of,  23 
cryoscopy  in,  24 

fibrin  in,  25 

glucose  in,  26 

melanin  in,  27 

nucleo-albumin  in,  25 

parasites  of,  27 

peptones  in,  25 
Urticaria,  90 

of  foot,  562 

of  penis,  641 
Uterus,  bicornate,  720 

carcinoma  of,  722 

chorio-epithelioma  of,  726 

descending,  720 

displacements  of,  720 

double,  720 

fibroids  of,  724 

hematometra  of,  726 

infantile,  720 

inflammations  of,  721 

inversion  of,  726 

malformations  of,  720 

newgro'wiihs  of,  722 

physometra  of,  726 

prolapse  of,  720 

pyometra  of,  726 

retroposition  of,  720 

sarcoma  of,  723 

septate,  720 

tuberculosis  of,  726 
Uveitis,  267 


Vagina,  absence  of,  713 

atresia  of,  713 

carcinoma  of,  714 

cysts  of,  714 

fibromyoma  of,  714 

inflammation  of,  713 

malformations  of,  713 

sarcoma  of,  714 

tmnors  of,  714 
Vaginitis,  713 
Varices  of  esophagus,  474 
Varicocele,  659 
Varicose  veins  of  leg,  580 

of  vulva,  709 
Vascular  goitre  of  neck,  315 

keratitis,  267 

wounds  of  neck,  309 
Venereal  warts  of  cervix,  717 

of  vulva,  709 
Venous  hemorrhoids,  551 
Ventral  hernia,  506 
Verruca  of  scalp,  238 
Vertebrae,  caries  of,  x-rays  in  diagnosis  of, 
57 

fractures  of,  rc-rays  in  diagnosis  of,  57 

injury  of,  207 

sprain  of,  207 

syphilis  of_,  343 

tuberculosis  of,  340 

tumors  of,  206,  343 

a;-rays  in  diagnosis  of,  57 

wounds  of,  340 
Vesical  calculus,  675,  736 

a;-rays  in  diagnosis  of,  63 

fistula,  735 

sphincter,  internal,   contracture   of, 
664  _ 
sclerosis  of,  664 
Vesiculitis,  acute,  660,  661 
Visual  centres  of  brain,  144 

tumors  of,  176 
Vitelline  duct,  persistent,  489 
Volkmann's  contracture  of  hand,  348 
Volvulus  of  stomach,  513 
Vomiting,  postoperative,  78 
Vulva,  carcinoma  of,  710 

chancre  of,  709 

chancroid  of,  709 

elephantiasis  of,  708 

enlargements  of,  709 

fibromyoma  of,  712 

hematoma  of,  710 

herpes  of,  709 

infantile,  707 

inflammation  of,  707 

lipoma  of,  712 

lupus  of,  712 

malformations  of,  707 

sarcoma  of,  712 

syphilis  of,  709 

tumors  of,  709 

varicose  veins  of,  709 

venereal  warts  of,  709 
Vulvitis,  707 


INDEX 


771 


Vulvovaginal  glands,  abscess  of,  712 
cysts  of,  713 
inflammation  of,  712 


W 


Warts,  94 

of  scalp,  238 

venereal,  of  cervix,  717 
of  vulva,  709 
Wasserman    reaction    in    diagnosis    of 

syphilis,  35 
Wens,  240 
Widal  reaction,  22 
Word  blindness,  144 
Wounds  of  arm,  418 

of  bladder,  673 

of  bloodvessels,  96 

of  buttocks,  633 

of  chest,  453 

of  ear,  254 

of  elbow,  390 

of  forearm,  379 

of  heart,  453 

of  joints,  131 

of  knee,  598 

of  lungs,  453 

of  neck,  vascular,  309 

of  penis,  640 

of  skull,  231,232 

of  spine,  340 

of  spleen,  530 

of  stomach,  511 

of  tendons,  112 

of  thoracic  duct,  101 

of  tympanum,  254 

of  ureters,  680 

of  vertebrae,  340 
Wrist,  arthritis  of,  366,  367 

bones  of,  dislocations  of,  358 
fractures  of,  352 
inflammations  of,  366 

dislocations  of,  357 

drop,  347 

inflammation  of,  358 

joints  of,  inflammations  of,  366 
peri-arthritis  of,  366 

sprains  of,  349,  352 

subluxation  of,  358 

tumors  of,  368 
Writer's  cramp,  348 
Wry-neck,  218 

acquired,  309 

congenital,  307 


Xanthoma  of  eyelids,  260 
Xerosis  of  conjunctiva,  263 
X-rays  in  diagnosis  of  abdominal  aneu- 
rysms, 64 
tumors,  65 
of  abscess  of  lung,  61 
of  achondroplasia,  42 


X-rays  in  diagnosis  of  acromegaly,  42 
of  aneurysms,  59 
of  arteriosclerosis,  66 
of  arthritis,  49 

acute,  49 

chronic,  49 

non-tuberculous,  50 
tuberculous,  49 

gouty,  53 

infectious,  52 

of  spinal  column,  58 
of  arthropathies,  53 
of  biliary  calculus,  64 
of  bone  cysts,  44 
of  bunion,  54 
of  bursitis,  66 
of  carcinoma  of  bone,  45 
of  caries  of  vertebrae,  57 
of  cervical  rib,  54 
of  coxa  vara,  54 
of  deformities  of  ribs,  57 
of  diseases  of  bones,  37 

of  colon,  66 

of  esophagus,  65 

of  gall-bladder,  64 

of  joints,  37 

of  liver,  64 

of  lumbar  spine,  65 

of  nose,  54 

of  pancreas,  64 

of  sigmoid,  66 

of  small  intestine,  66 

of  spleen,  64 

of  sternum,  57 

of  stomach,  65 

of  teeth,  55 
of  dislocations,  46 

acromioclavicular,  47 

of  carpal  bones,  47 

of  elbow-joint,  47 

of  hip,  congenital,  47,  54 
traumatic,  47 

of  shoulder- joint,  47 

of  sternum,  57 

of  tarsus,  49 
of  empyema,  62 
of  enchondroma  of  bone,  45 
of  epiphyseal  separations,  39 
of  epiphysitis,  39 
of  foreign  bodies  in  abdomen,  64 
in  bladder,  64 
in  bronchi,  59 
in  esophagus,  58 
in  eye,  54 
in  head,  54 
in  larynx,  59 
in  orbit,  54 
in  pelvis,  64 
in  trachea,  59 
of  fractures  of,  37 

of  ribs,  56 

of  sterniun,  57 

of  vertebrse,  57 
of  fragilitas  ossiimi,  42 
of  gangrene  of  lung,  61 
of  genu  valgxmi,  54 


772 


INDEX 


X-rays  in  diagnosis  of  genu  varum,  54 

jf  gunshot  injuries  of  thorax,  5f 
of  hereditary  syphilis  of  bone, 

42 
of  hydronephrosis,  63 
of  inflammations  of  bones,  39 
of  loose  bodies  in  joints,  53 
of  myositis,  66 
of  nephroptosis,  63 
of  osteitis  deformans,  42 
of  osteoma,  45 
of  osteomyelitis,  39 
of  osteoperiostitis,  56 
of  osteosarcoma,  44 
of  painful  stump,  67 
of  perinephric  abscess,  63 
of  periosteitis,  39 
of  pleural  effusions,  62 
of  pneumonia,  61 
of  post-typhoidal  osteitis,  42 
cf  prostatic  calculi,  63 


X  rays  in  diagnosis  of  pyonephrosis,  63 
of  renal  calculus,  62 
of  rickets,  43 
of  rupture  of  muscles,  67 
of  salivary  calculus,  55 
of  sarcoma  of  bone,  41,  43 
of  scoliosis,  54,  58 
of  subphrenic  abscess,  62 
of  syphilis  of  bones,  40 
of  syphilitic  dactylitis,  42 
of  traumatic  aneurysms,  66 
of  tuberculosis  of  bones,  39 
of  tumors  of  bone,  43 

of  brain,  55 

of  kidney,  63 

of  lower  jaw,  55 

of  ribs,  57 

of  skull,  55 

of  sternum,  57 

of  vertebra,  57 
of  vesical  calculus,  63 


COLUMBIA  UNIVERSITY  LIBRARIES  (hsl.stx) 
Surgical  diagnosis, 


2002125536 


n'i^- 


9^  S.  ^^S^^v^^'t^^^ 


